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FIG.  1.— The  facial  expression  of  the  normal,  healthy  baby. 


Page  30. 


[SIMPLIFIED    INFANT 
FEEDING     7 

WITH  EIGHTY  ILLUSTRATIVE  CASES 


V    BY 
ROGER  H.  DENNETT,  B.S.,  M.D. 

ASSOCIATE  PROFESSOR  OF  DISEASES  OF  CHILDREN,  NEW  YORK  POST-GRADUATE  MEDICAL  SCHOOL 

ATTENDING  PHYSICIAN  OF  THE  CHILDREN'S  DEPARTMENT,  NEW  YORK  POST-GRADUATB 

HOSPITAL;   ASSISTANT   ATTENDING   PHYSICIAN   AT   THE   WILLARD   PARKER 

HOSPITAL  AND  PEDIATRIST  TO  THE  NEW  YORK  LYING-IN  HOSPITAL 


WITH  14  ILLUSTRATIONS 


SECOND  EDITION  REVISED  AND  ENLARGED 


PHILADELPHIA  AND  LONDON 
J.   B.    LIPPINCOTT   COMPANY 


\K)S 


COPYRIGHT,  IPIS,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  1920,  BY  J.  B.  LIPPINCOTT  COMPANY 


Electrotyped  and  Printed  by  J.  B.  Lippincott  Company 
The  Washington  Square  Press.  Philadelphia.  U.  S.  A. 


PREFACE  TO  THE  SECOND  EDITION 

IN  rewriting  this  book  for  the  second  edition,  it  is  grati- 
fying to  find  that  the  method  described  in  the  first  edition, 
written  five  years  ago,  has  stood  the  test  of  time.  It  is  grati- 
fying because,  up  to  six  or  seven  years  ago,  the  subject  of 
infant  feeding  had  undergone  so  many  and  such  radical 
changes.  The  usefulness  of  boiled  milk,  which  at  that  time 
was  scorned  by  many,  is  now  almost  universally  accepted 
by  the  pediatricians  of  this  country,  and  the  simple  dilu- 
tions have  come  to  stay. 

Although  the  method  itself  has  not  been  changed,  there 
have  been  new  and  helpful  additions  to  our  knowledge  of 
infant  feeding  as  we  expect  and  hope  there  will  be  for  years 
to  come.  It  has  been  attempted  to  bring  this  book  up  to  date 
by  including  in  it  these  newer  things  in  so  far  as  they  have 
proved  useful  to  the  author.  There  is  new  matter  on  Dry 
Milk,  Acidosis,  Salts  of  Milk  and  the  Hypertonic  Infant. 
The  chapters  on  DiarrhxBa  have  been  extensively  revised. 

For  the  chapter  on  Acidosis,  the  author  is  indebted  to 
Dr.  Marshall  C.  Pease;  for  the  chapter  on  Salts  of  Milk,  to 
Dr.  Henry  I.  Bowditch  and  Dr.  A.  W.  Bosworth,  of  the 
Boston  Floating  Hospital. 

The  book  was  never  meant  to  be  a  review  of  the  literature 
of  infant  feeding,  for  there  are  a  number  of  excellent  books 
of  that  type.  It  was  written  to  help  the  general  practitioner, 
particularly  the  post-graduate  student,  to  successfully  feed 
his  babies  as  they  occur  in  his  practice. 

ROGER  H.  DENNETT. 

125  East  39th  Street,  New  York,  N.  Y. 
January,  1920. 


iii 


PREFACE  TO  THE  FIRST  EDITION 

EXTENSIVE  experience  in  teaching  post-graduate  students 
the  subject  of  infant  feeding  has  shown  the  need  of  some- 
thing concrete  in  the  form  of  a  book  that  will  tell  the  busy 
practitioner  just  how  to  feed  the  different  babies  with  whom 
he  comes  in  contact  day  after  day. 

There  has  been  so  much  written  upon  the  theory  of  infant 
feeding  that  the  general  practitioner  is  lost  in  its  mazes, 
since  the  theories  are  constantly  changing  and  eminent  pedi- 
atricians differ  so  widely  in  their  ideas  upon  the  subject. 

That  is  the  reason  that  "theory"  has  been  left  out  of 
this  book  as  much  as  it  has  been  possible  to  do  so,  using 
facts  and  rules  where  they  can  be  made  to  apply. 

The  book  that  tells  in  detail  just  how  to  feed  an  infant 
is  of  much  more  assistance  to  a  physician  than  one  which 
deals  in  generalities.  There  seems  to  be  much  objection  to 
the  words  " method "  and  "system"  in  describing  infant 
feeding.  It  is  very  popular  to  say  that  "every  case  i§  a 
law  unto  itself."  Such  a  statement  tells  nothing  and  is, 
moreover,  not  true.  In  every  other  branch  of  medicine,  we 
have  a  definite  method  of  procedure,  and  while  it  is  true 
that  there  are  individual  peculiarities  of  infants,  they  may 
be  classified  to  a  certain  extent,  at  least,  as  the  author  has 
undertaken  to  do  in  this  work. 

Dr.  Abraham  Jacob!  in  taking  issue  with  the  statement 
that  to  speak  of  a  "method"  of  infant  feeding  is  taking  a 
distinct  step  backward,  said,  "It  is  possible  to  be  guided  by 
the  rule.  Not  every  case  needs  to  be  fed  from  the  individual 
standpoint  from  the  beginning.  The  general  rule  might  be 
applied  at  first,  and  only  when  the  individual  does  not  de- 
velop properly  under  the  rule  may  the  physician  show  his 


vi  PREFACE 

shrewdness  in  meeting  the  special  requirements   of  the 
individual. ' ' 

The  chief  fact  remains  that  most  excellent  results  have 
been  obtained  in  following  out  the  system  described  in  this 
book. 

The  author  wishes  to  acknowledge  his  indebtedness  to 
Dr.  Marshall  C.  Pease  for  his  kindly  criticism  and  helpful- 
ness in  the  preparation  of  this  book. 

ROGEB  H.  DENNETT. 

125  East  39th  Street,  New  York,  N.  Y. 
January,  1915. 


CONTENTS 


CHAPTER  PAGE 

I.  SYNOPSIS  OF  TEXT 1 

II.  SOME  POINTS  ON  INFANTS  IN  GENERAL  WITH  SPECIAL  REFERENCE 

TO  BOTTLE-FED  BABIES 22 

III.  THE  THREE  ESSENTIAL  REQUIREMENTS  FOR  INFANTS'  FOODS...  37 

IV.  DIGESTIBILITY  OF  THE  FOOD 42 

V.  THE  PROPER  QUANTITY  OF  FOOD  TO  SUPPLY  THE  CALORIC  NEEDS  57 

VI.  CONDITIONS  UNDER  WHICH  THE  CALORIC  REQUIREMENTS  SHOULD 

NOT  BE  FULFILLED 74 

VII.  THE  STOOLS 93 

VIII.  THE  CLASSIFICATION  AND  DIAGNOSIS  OF  DIARRHEAS  IN  BOTTLE- 
FED  INFANTS 100 

IX.  TREATMENT  OF  DIARRHEAS  IN  BOTTLE-FED  INFANTS 115 

X.  FIRST  METHOD  OF  TREATING  DIARRHCEA 118 

XI.  SECOND  METHOD  OF  TREATING  DIARRHCEA 139 

XII.  THIRD  METHOD  OF  TREATING  DIARRHOEA 147 

XIII.  ACIDOSIS  ACCOMPANYING  INTESTINAL  INTOXICATION 160 

XIV.  CONSTIPATION  IN  BOTTLE-FED  INFANTS 170 

XV.  VOMITING  IN  BOTTLE-FED  INFANTS 184 

XVI.  Loss  OF  APPETITE  IN  BOTTLE-FED  INFANTS 209 

XVII.  BREAST  FEEDING 220 

XVIII.  COMBINED  BREAST  AND  BOTTLE  FEEDING 244 

XIX.    CONTRA-INDICATIONS   FOR   BREAST   FEEDING 250 

XX.  BREAST  WEANING  (8  TO  12  MONTHS  OF  AGE) 258 

XXI.  DIARRHCEA,  VOMITING,  AND  CONSTIPATION  IN  BREAST-FED  INFANTS  264 
XXII.  THE  USE  OF  BOILED  MILK  IN  INFANT  FEEDING 275 

XXIII.  DRY  MILK 291 

XXIV.  MALT  SOUP  MIXTURES 302 

XXV.  SALTS  OF  MILK 309 

XXVI.  BOTTLE  WEANING  AND  FOOD  FOR  OLDER  CHILDREN 315 

XXVII.  THE   PREMATURE    INFANT — FOOD    FOR   TRAVELLING — WATER — 

LAVAGE — GAVAGE — IRRIGATING  THE  BOWELS 332 

XXVIII.  NORMAL  DEVELOPMENT  OF  INFANTS 343 

XXIX.  Cow's  MILK 347 

XXX.  PROPRIETARY  FOODS 361 

LIST  OF  CASES 374 

LIST  OF  TABLES 378 

CALORIC  VALUE  OF  MILK  WITH  DIFFERENT  FAT  PERCENTAGES.  . .  379 
INDEX . .  .381 


Vll 


ILLUSTRATIONS 


FIG.  PAGE 

1.  THE  FACIAL  EXPRESSION  OF  THE  NORMAL,  HEALTHY  BABY.  .Frontispiece 

2.  EXCELLENT  AND  INEXPENSIVE  BABY  SCALES 26 

3.  FACIAL  EXPRESSION  OF  AN  INFANT  WITH  GASTRO-ENTERITIS,  AND  ONE 

WITH  ATROPHY  (MARASMUS) 30 

4.  THE  PROPER  PARAPHERNALIA  FOR  BOTTLE  FEEDING 34 

5.  SHOWING    EMACIATED,     POORLY    NOURISHED,     MODERATELY    WELL- 

NOURISHED,  AND  WELL-NOURISHED  INFANTS 58 

6.  IRRIGATING  THE  BOWEL 152 

7.  INSERTING  THE  TUBE  FOR  STOMACH  WASHING 186 

8.  POURING  IN  THE  WATER  FOR  STOMACH  WASHING 187 

9.  EMPTYING  THE  STOMACH 186 

10.  CORRECT  WAY  TO  GIVE  A  BOTTLE  FEEDING 192 

11.  THE  STOMACH  TUBE  FOR  GAVAGE 216 

12.  THE  CORRECT  WAY  TO  GIVE  A  BREAST  FEEDING 220 

13.  POSITION  IN  WHICH  TO  HOLD  BABY  WHEN  MILK  FLOWS  TOO  RAPIDLY  234 

14.  SCURVY,  WITH  SWELLING  OVER  TIBIA  AND  FEMUR  OF  BOTH  LEGS.  . . .  276 


SIMPLIFIED    INFANT  FEEDING 

CHAPTER  I 
SYNOPSIS  OF  TEXT 

SOME    POINTS    ON    INFANTS    IN    GENERAL   WITH    SPECIAL 
REFERENCE  TO  BOTTLE-FED  BABIES 

HISTORY  TAKING   (page  22) 

The  following  points  in  the  history  must  always  be 
ascertained : 

(1)  Feeding  history  of  previous  children. 

(2)  How  long  breast-fed. 

(3)  Food  previously  taken. 

(4)  Number  of  feedings.    Intervals  and  quantity  of  food 

taken. 

(5)  The  bowels. 

(a)  How  long  have  they  been  in  the  present  condi- 

tion! 

(b)  Number  of  stools? 

(c)  Color? 

(d)  Consistency? 

(e)  Presence  of  mucus  ? 

(f)  Curds? 

(g)  Blood? 

(h)  Use  of  cathartics? 

(6)  Vomiting. 

(a)  Duration. 

(b)  Quantity, 


2  SIMPLIFIED  INFANT  FEEDING 

(c)  The  time  (before  or  after  a  feeding,  or  continu- 

ous). 

(d)  Character  (projectile?). 

(7)  Appetite. 

( a)  Is  all  the  food  taken  ? 

(b)  Is  any  of  the  food  thrown  away? 

(c)  Is  the  baby  satisfied? 

(8)  Sleep. 

(a)  Morning. 

(b)  Afternoon. 

(c)  Night. 

PHYSICAL  EXAMINATION 

(1)  Weight:  Normal  infants  gain  from  six  to  eight  ounces 

a  week  under  six  months  of  age,  three  to  four  ounces 
a  week  over  that  age.  The  birth  weight  is  doubled 
in  six  months,  trebled  in  a  year. 

(a)  Birth  weight. 

(b)  Lowest  weight  since  birth. 

(c)  Present  weight. 

(d)  Gain  or  loss  each  week. 

(2)  Color :  Pallor  is  seen  in  difficult  feeding  cases  resulting 

in  anaemia: 

(a)  Fat  babies  over  six  months  of  age,  incorrectly 

fed  (condensed  milk). 

(b)  Prolonged  indigestion. 

(c)  Atrophy  (marasmus). 

(3)  Skin  (wrinkled,  inelastic  skin  of  bad  import) :  Bough- 

ness,  scaling,  furunculosis,  intertrigo,  prickly  heat 
and  eczema  seen  in  difficult  feeding  cases. 

(4)  Development  and  nutrition. 

(a)  Fat. 

(b)  Well  nourished. 

(c)  Moderately  well  nourished. 

(d)  Poorly  nourished. 

(e)  Emaciated. 

(f)  Atrophic  (dried  up). 


SYNOPSIS  OF  TEXT  3 

(g)  Poor  musculature. 

(h)  Undersized  (small  in  stature ;  small  for  its  age) , 

(5)  Temperature. 

(6)  Mouth. 

(a)  Stomatitis. 

(b)  Eed  mouth  (beefy  tongue). 

(c)  Coated  tongue. 

(d)  Teething. 

(7)  Facial  expression. 

(8)  Heart  and  lungs. 

(9)  Abdomen. 

(a)  Distention. 

(b)  Sunken  abdomen. 

(c)  Loss  of  abdominal  tone. 

(d)  Enlarged  spleen  and  liver,  abnormal  masses, 

fluid. 

(10)  Evidences  of  rickets. 

Head'- 

(a)  Abnormally  large  head. 

(b)  Abnormally  large  f  ontanel. 

(c)  Delayed  closure  of  sutures  and  fontaneL 

(d)  Square  box-shaped  head. 

(e)  Bald  spot  on  the  back  of  the  head. 
Chest: 

(a)  Beading. 

(b)  Pigeon  breast. 

(c)  Flaring  of  the  ribs. 

(d)  Harrison's  groove. 

(e)  Soft  ribs  sinking  in  on  inspiration. 
Extremities : 

Enlarged  epiphyses  at  the  wrists  and  ankles. 

DIRECTIONS  FOB  MAKING  BABIES '  FOODS 

(1)  Write  all  directions. 

(2)  Write  the  number  of  ounces  of  milk,  water,  sugar  and 

other  ingredients. 


4  SIMPLIFIED  INFANT  FEEDING 

(3)  Make  up  the  twenty-four-hour  amount  of  food  at  the 

same  time  each  day. 

(4)  Divide  the  total  quantity  into  as  many  bottles  as  there 

are  to  be  feedings  in  twenty-four  hours. 

(5)  State  the  approximate  quantity  at  each  feeding,  the  in- 

tervals and  the  exact  time  at  which  each  feeding 
should  come. 

BOTTLES,  NIPPLES  AND  UTENSILS  FOB  MAKING  THE  FOOD 

(1)  Direct  the  mother  to  purchase  the  proper  utensils :  8  or 

10  bottles,  3  or  4  nipples,  measuring  glass,  wire  bottle 
rack,  bottle  brush. 

(2)  Give  directions  for  the  care  of  the  bottle,  nipples,  and 

food. 

THREE  ESSENTIAL  REQUIREMENTS  FOR 
INFANTS'  FOOD 

(1)  It  should  contain  the  proper  elements  to  maintain  nutri- 

tion and  allow  for  growth. 

(2)  It  should  be  digestible. 

(3)  It  should  contain  the  proper  quantity  of  food,  which  is 

best  estimated  by  caloric  standards. 

THE  PROPER  ELEMENTS  IN  THE  FOOD 

(Proteids,  fats,  sugars,  mineral  salts  and  water) 
Breast  milk  contains  from  3  to  4  per  cent,  fat,  6  to  7  per 
cent,  sugar,  1  to  2  per  cent,  proteid.    A  food  of  cow's  milk 
made    to    approximate    these   percentages    is    not    easily 
digested.    The  fats,  sugars  and  proteids  are  interchange- 
able to  a  limited  extent. 
(1)  The  proteids. 

Some  proteid  is  essential  for  cell  construction  and  to 
replace  the  nitrogenous  waste.  Cow 's  milk  diluted  one-third 
gives  1  per  cent,  proteid  in  the  food,  diluted  half  and  half  it 
gives  1.1/2  per  cent,  proteid  in  the  food,  approximating  the 
percentage  of  proteid  in  breast  milk. 


SYNOPSIS  OF  TEXT  5 

(2)  The  fats. 

Fats  save  nitrogenous  waste,  supply  heat  and  energy  and 
add  to  the  body  weight  by  storing  up  fat.  Average  cow's 
milk  diluted  three  times  gives  1%  per  cent,  fat,  diluted  twice 
gives  2  per  cent.  Since  breast  milk  contains  from  3  to  4  per 
cent,  fat,  the  deficiency  in  cow 's  milk  is  made  up  with  sugar. 

(3)  The  sugars. 

Sugar  supplies  heat  and  energy  and  replaces  fat  waste 
in  the  body.  The  sugars  used  in  infant  feeding  are  cane 
sugar,  milk  sugar,  and  malt  sugar,  one  of  which  must  be 
added  to  supply  the  deficiency  of  sugar  in  cow's  milk,  since 
when  diluted  three  times  it  contains  only  1%  per  cent,  of 
sugar  and  diluted  half  and  half  gives  but  2  per  cent. 

(4)  The  mineral  salts. 

Salts  are  furnished  in  abundance  in  both  human  and 
cow's  milk. 

(5)  The  water. 

The  food  of  all  young  mammals  contains  from  80  per  cent, 
to  90  per  cent,  water. 

DIGESTIBILITY  OF  THE  FOOD 

Simple  milk,  sugar  and  water  mixtures  are  most  easily 
digested. 
(1)  Theproteids. 

The  proteids  are  made  up  of  %  casein  (curds)  and  14 
albuminous  proteid  (whey).  The  curds  are  no  longer  con- 
sidered as  indigestible  as  formerly. 

The  former  methods,  now  discarded,  of  making  the  pro- 
teids more  digestible  were: 

(a)  "Split  proteins"  (whey,  cream  and  sugar  mixtures). 

(b)  Lime  water. 

(c)  Stronger  alkalies  like  sodium  bicarbonate  and  sodium 

citrate. 

(d)  Gruels. 

(e)  Peptonizing. 


6  SIMPLIFIED  INFANT  FEEDING 

Boiling  the  milk  is  all  that  is  necessary  to  make  the  pro- 
teids  digestible  and  has  now  supplanted  the  other  methods. 

(2)  The  fats. 

A  mixture  made  of  cow's  milk  containing  4  per  cent,  fat, 
thus  imitating  the  percentage  of  fat  in  breast  milk,  is  not 
easily  digested  by  the  average  infant.  Cow's  milk  diluted 
one-third  gives  1%  per  cent,  fat,  diluted  half  and  half  gives 
2  per  cent.  fat.  This  amount  of  fat  is  digested  with  ease  by 
the  average  infant.  It  is  occasionally  necessary  to  use 
skimmed  milk  in  severe  cases  of  indigestion  caused  by  fat. 

(3)  The  sugar. 

Sugar  is  the  most  frequent  source  of  indigestion  of  any 
of  the  elements.  It  is  usually  a  laxative,  though  it  has 
not  been  settled  which  of  the  three  sugars  (cane  sugar,  milk 
sugar  or  malt  sugar)  is  the  most  laxative. 

The  author  advises  the  use  of : 

(a)  Cane  sugar  for  older  infants  and  those  with  no  intes- 
tinal or  gastric  indigestion. 

(b)  Malt  sugar  for  infants  having  had  much  intestinal 
trouble. 

(c)  Milk  sugar  not  at  all. 

(d)  Malt  soup  extract  and  wheat  flour  in  those  cases  that 
do  not  do  well  upon  any  other  kind  of  sugar. 

(e)  No  sugar  whatever  (temporarily)  in  infants  with 
diarrhoea  or  severe  vomiting. 

The  quantity  of  sugar. 

A  WELL  infant  under  ten  pounds  in  weight  should  receive 
one  ounce  of  sugar  in  twenty-four  hours,  a  WELL  infant  over 
ten  pounds  in  weight  may  have  l^/o  ounces  of  sugar  in  twenty- 
four  hours.  This  gives  in  the  mixture  six  or  seven  per  cent, 
of  sugar,  the  same  as  in  breast  milk.  Infants  with  vomiting, 
diarrhoea  or  lack  of  appetite  should  receive  no  sugar  tem- 
porarily. 

The  rapidity  with  which  the  sugar  is  increased  to  1  or  iy% 
ounces  depends  upon: 


SYNOPSIS  OF  TEXT  7 

(a)  Whether  the  infant  has  formerly  had  sugar  or  not. 

(b)  Whether  the  kind  of  sugar  is  being  changed  or  not. 

(c)  Whether  there  has  previously  been  any  diarrhoea  or 
vomiting  and  the  duration  of  that  diarrhoea  or  vomiting. 

THE  PROPER  QUANTITY  OF  FOOD  TO  SUPPLY  THE 
CALORIC  NEEDS 

Food  may  be  compared  with  fuel  in  a  furnace.  A  furnace 
requires  so  many  tons  of  coal  to  run  an  engine,  an  individual 
infant  needs  a  certain  amount  of  food  to  use  up  in  heat, 
energy  and  growth.  A  ton  of  coal  represents  a  definite  num- 
ber of  calories,  and  an  ounce  of  milk  or  an  ounce  of  sugar 
represents  a  definite  number  of  calories,  the  term  used  to 
express  food  value. 

CALORIC  VALUE  OF  INFANTS*  FOODS 
1  oz.  of  milk  =    20  calories. 

1  oz.  of  sugar  =  120  calories  (any  kind  of  sugar). 

(by  weight) 
1  oz.  of  flour  =  100  calories. 

(by  weight) 

1  oz.  malt  soup  extract  =    90  calories. 

2  scant  tablespoonfuls  of  malt  soup  extract  =  1  oz.  by  weight. 

2  level  tablespoonfuls  of  cane  sugar  =  1  oz.  by  weight. 

3  level  tablespoonfuls  of  milk  sugar  =  1  oz.  by  weight. 

4  level  tablespoonfuls  of  dextri-maltose  =  1  oz.  by  weight. 
4  level  tablespoonfuls  of  flour  =  1  oz.  by  weight. 

(tablespoons  to  be  levelled  with  a  knife) 

CALORIC  REQUIREMENTS  FOR  BOTTLE-FED  INFANTS 

Babies  do  not  all  require  the  same  number  of  calories. 

Fat  infants  over  four 
months  of  age need  40  to  45  cals.  per  Ib.  per  day. 

Average  infants  under 
four  months  of  age  and 
moderately  thin  babies 
of  any  age need  50  to  55  cals.  per  Ib.  per  day. 

Emaciated  infants  (vary- 
ing with  the  degree  of 
emaciation) need  60  to  65  cals.  per  Ib.  per  day. 


8  SIMPLIFIED  INFANT  FEEDING 

To  determine  the  number  of  calories  a  baby  needs  in  24  hours, 
multiply  the  weight  of  the  individual  infant  by  the  caloric 
requirements  per  pound.  Example : 

An  average  infant  3  months  of  age  weighing  12  Ibs. 
needs  50  calories  per  pound.  12  X  50  =  600  total  caloric 
requirements  in  24  hours. 

To  determine  the  amount  of  milk  needed  in  24  hours,  sub- 
tract the  caloric  value  of  the  sugar  (which  is  a  fixed  quan- 
tity) from  the  total  caloric  requirements.  Example : 

The  above  infant  needs  600  calories,  180  of  which 
(iy2  oz.  of  sugar  =  180  calories)  are  sugar.  600  -  180  — 
420,  number  of  calories  of  milk  needed. 

To  determine  the  number  of  ounces  of  milk  needed  in  24 
hours,  divide  the  number  of  calories  of  milk  by  20  (1  oz. 
milk  ==  20  calories)  420  -5-  20  =  21. 

To  determine  the  quantity  of  water,  subtract  the  amount  of 
milk  from  the  total  24-hour  amount  of  food  that  the  indi- 
vidual infant  can  take,  trying  to  make  the  dilution  no 
stronger  than  half  and  half  for  infants  under  four  months 
of  age,  or  those  who  have  recently  recovered  from  vomit- 
ing or  diarrhea. 

To  determine  the  24-hour  quantity  of  food,  multiply  the  num- 
ber of  feedings  by  the  number  of  ounces  taken  at  a  feeding. 

The  quantity  of  food  given  at  each  feeding  is  from  one  to 
two  ounces  more  than  the  number  of  months  of  the  infant 's 
age,  with  a  maximum  of  eight  ounces,  and  a  minimum  of 
three  or  four  ounces,  though  undersized  infants  can  often 
take  only  one  ounce  for  each  month  of  their  age. 

The  number  of  feedings  in  twenty-four  hours  during  the  first 
four  months  is  usually  seven,  best  given  at  6,  9,  12  A.M., 
3,  6,  9  P.M.,  and  2  A.M. 

After  four  or  five  months  of  age,  six  feedings  in 
twenty-four  hours  may  be  given  at  6,  9,  12  A.M.,  and  3,  6, 
9  P.M. 

A    few   undersized    and   feeble   infants   under   four 


SYNOPSIS  OF  TEXT  9 

months  of  age  may  be  given  ten  feedings  in  twenty-four 
hours,  that  is  once  in  two  hours  at  6,  8, 10  A.M.,  12  M.,  2,  4, 
6,  8, 10  P.M.,  and  2  A.M. 

A  BOUGH  RULE  TO  TAKE  THE  PLACE  OF  RECKONING  CALORIES 

The  average  infant  having  no  digestive  disturbances  re- 
quires in  twenty-four  hours  twice  as  many  ounces  of  milk 
as  he  weighs  in  pounds,  provided  he  can  take  iy2  ounces  of 
sugar.  This  rule  is  a  rough  one  only.  Thin  or  emaciated 
infants  need  more.  Fat  infants  need  less. 

CONDITIONS  UNDER  WHICH  THE  CALORIC  REQUIREMENTS 
SHOULD  NOT  BE  FULFILLED 

One  of  the  first  principles  of  caloric  feedings  is  never 
to  fulfil  the  caloric  requirements  in  the  following  classes 
of  infants : 

(1)  In  the  newborn  (for  the  first  two  weeks). 

(2)  Normal  infants  abruptly  weaned  from  the  breast 
(until  their  tolerance  for  food  can  be  gradually  increased). 

(3)  Infants  whose  previous  food  has  not  contained  cow's 
milk  (until  the  milk  and  sugar  can  be  gradually  increased). 

(4)  Infants  who  have  been  overfed  (until  their  digestive 
apparatus  has  had  a  chance  to  recuperate). 

(5)  Infants  who  have  been  underfed  (until  their  toler- 
ance for  food  has  been  gradually  increased). 

(6)  Infants  who  have  diarrhoea  or  who  have  recently 
recovered  from  diarrhoea  (until  the  stools  have  become  nor- 
mal and  the  tolerance  for  food  has  been  gradually  increased) . 

( 7 )  Infants  who  have  excessive  vomiting  or  have  recently 
recovered  from   excessive   vomiting    (until   vomiting  has 
stopped  and  the  tolerance  for  food  increased). 

(8)  Infants  with  loss  of  appetite  (until  all  food  is  greed- 
ily taken). 

(9)  Infants  who  are  partially  breast  fed  (until  they  are 
entirely  weaned,  because  it  is  not  known  how  many  calories 
they  are  getting  from  the  breast). 


10  SIMPLIFIED  INFANT  FEEDING 

DIARRHCEA  IN  BOTTLE-FED  INFANTS 

Diarrhoea  in  bottle-fed  infants  is  more  often  the  result 
of  intestinal  indigestion  due  to  incorrect  feeding  than  to 
bacterial  infection. 

A  routine  treatment  of  a  cathartic  followed  by  a  period 
of  starvation  should  not  be  adopted  because  in  such  cases 
the  bowel  is  usually  emptied  of  its  own  accord  and  starvation 
weakens  the  infant  unnecessarily. 

The  physician  should  personally  inspect  the  stools  and 
determine  the 

1.  Duration  of  the  diar-      6.  Odor. 

rhcea,  7.  Eeaction. 

2.  Number  of  stools  in  24      8.  Presence  of  mucus. 

hours.  9.  Presence  of  curds. 

3.  Size.  10.  Presence  of  blood. 

4.  Color.  11.  Whether  cathartics  have 

5.  Consistency.  been  administered  or 

not. 

THE  CLASSIFICATION  AND  DIAGNOSIS  OF  DIARRHCEA 
IN  BOTTLE-FED  INFANTS 

INTESTINAL,  INDIGESTION 

(Dyspepsia,  Lowered  Tolerance  for  Food) 

ffat. 

1.  Simple  intestinal  indigestion  from  < 

)  proteid. 

I  starch. 

2.  Underfeeding. 

3.  Overfeeding. 

4.  Recurrent  diarrhoea  due  to  lowered  tolerance  that  can- 

not be  raised  by  the  usual  methods  above  a  point 
where  a  proper  and  continuous  gain  in  weight  may 
be  made. 


SYNOPSIS  OF  TEXT  11 

INFECTIOUS  DIARRHOEA 

1.  Fermentative  diarrhoea  (dyspepsia,  sugar  or  starch 

diarrhoea,  sugar  intoxication). 

2.  Putrefactive  diarrhoea  (proteid  diarrhoea). 

3.  Mild  types  of  infectious  diarrhoea. 

4.  Dysentery  (acute  infectious  diarrhoea,  ileocolitis,  in- 

toxication). 

5.  Cholera  infantum  (intoxication). 

MISCELLANEOUS 

1.  Sugar  intoxication. 

2.  Mechanical  diarrhoea. 

3.  Diarrhoea  from  cathartics. 

4.  Marasmus  (lost  power  of  assimilation,  decomposition, 

atrophy). 

5.  Other   organic   causes:   typhoid,   amoebic  dysentery, 

tuberculosis,  ulcer,  intussusception. 

TREATMENT  OF  DIARRHCEA  IN  BOTTLE-FED  INFANTS 

First  Method :    PROTEIN  DIET — 

(a)  Stop  all  sugar.     (Be  sure  the  mother  is  not  giving 

sugar  and  water  between  feedings.) 

(b)  Feed  one-third  whole  milk  and  two-thirds  water  as 

routine,    or    one-half    fat-free    milk    and    one- 
half  water. 

(c)  Boil  the  milk  and  water  together. 

(d)  Avoid  cathartics. 

(e)  Use  protein  milk. 
Indications : 

fat. 


(1)  Simple  intestinal  indigestion  from 


sugar. 


proteid. 
starch. 

(2)  Underfeeding,  accompanied  by  intestinal  indigestion. 

(3)  Overfeeding,  accompanied  by  intestinal  indigestion. 

(4)  Fermentative  infectious  diarrhoea. 


12  SIMPLIFIED  INFANT  FEEDING 

Second  Method :    CAEBOHYDBATE  DIET — 

( a)  Barley  gruel  made  without  milk. 

(b)  Thick  gruels  of  various  kinds,  such  as  cornstarch, 

arrowroot,  etc.,  fed  with  spoon.    Breadstuffs. 

(c)  The  gruels  cooked  with  part  fat-free  milk. 
Indications : 

(1)  Putrefactive  diarrhceia. 

(2)  Most  infectious  diarrhoea  occurring  in  infants  six 

months  of  age  or  over. 

(3)  Chronic  diarrhoea  in  older  children. 

(4)  Infants  over  six  months  of  age  who  are  not  improved 

after  a  thorough  trial  of  the  protein  diet. 
Third  Method: 

(a)  Cathartic  followed  by 

(b)  A  twenty-four-hour  period  of  starvation  with  plain 

unsweetened  water,  which  is  followed  by 

(c)  A  gruel  or  starch  diet. 
Indications : 

'(1)  Mild  types  of  infectious  diarrhoea. 

(2)  Dysentery. 

(3)  Cholera  mfantum. 

(4)  Sugar  intoxication. 

(5)  Mechanical  diarrhoea. 

DIFFERENTIAL  DIAGNOSIS  OF  DIARRHCEA 

(1)  Intestinal  indigestion. 

(2)  Fermentative  diarrhoea. 

(3)  Putrefactive  diarrhoea. 

(4)  Dysentery. 

(5)  Cholera  mfantum. 

(6)  Sugar  intoxication. 

(7)  Mechanical  diarrhoea. 
Distinguishing  features : 

(1)  Onset. 

(2)  Nutrition. 

(3)  Other  symptoms. 


SYNOPSIS  OF  TEXT  13 

(4)  Fever. 

(5)  Cause. 

(6)  Therapeutic  test. 

(7)  Stools. 

CONSTIPATION  IN  BOTTLE-FED  INFANTS 

Causes  and  treatment  of  constipation  in  the  bottle-fed. 

(1)  Gastric  indigestion. 

(a)  Treatment  must  be  appropriate  for  the  causa- 
tive factor. 

(2)  Too  much  fat. 

(a)  Eliminate  cream  or  top  milk  in  food;  give 
proper  quantities  of  whole  milk,  water  and 
sugar  mixtures. 

(3)  Too  much  sugar. 

(a)  With  constipated  infants  consuming  two 
ounces  or  one  and  a  half  ounces  of  sugar 
in  twenty-four  hours,  reduce  the  amount  to 
one  ounce,  strengthening  the  milk  to  fulfil 
the  caloric  requirements.  (The  normal 
amount  of  sugar  for  an  infant  under  ten 
pounds  of  weight  is  one  ounce  in  the  twenty- 
four-hour  amount.  Infants  weighing  more 
than  ten  pounds  may  have  one  and  one-half 
ounces.  Two  ounces  is  the  maximum  quan- 
tity of  sugar  to  use  in  twenty-four  hours 
and  that  only  rarely.) 

(4)  Too  little  sugar. 

(a)  Gradually  increase  the  sugar  to  the  proper 
quantity  for  the  infant's  age  when  consti- 
pation is  found  in  infants  fed  with  too  little 
sugar. 

(5)  Too  little  or  too  weak  food  having  little  residue. 

(a)  If  too  weak  dilutions  of  milk  and  water  are 
being  used,  they  should  be  increased. 


14  SIMPLIFIED  INFANT  FEEDING 

Xb)  If  any  proprietary  food  without  milk  is  being 
used  it  should  be  stopped  and  dilutions  of 
milk  given,  usually  one-third  milk  and  two- 
thirds  water  at  first. 

(c)  If  no  sugar  has  been  given,  it  should  be  added, 

a  teaspoonful  at  a  time,  until  the  correct 
amount  is  given. 

(d)  If  the  amount  of  sugar  in  the  previous  food 

has  been  correct  it  may  be  gradually  in- 
creased, provided  there  is  no  vomiting  or 
lack  of  appetite. 

(6)  Excessive  vomiting  or  lack  of  appetite. 

(a)  For  treatment,  see  Vomiting  and  Lack  of 
Appetite. 

(7)  Boiled  milk. 

(a)  When  milk  has  been  boiled  to  remedy  diar- 

rhoea or  vomiting,  the  symptoms  of  which 
have  ceased,  it  may  be  given  raw. 

(b)  When  vomiting  is  present,  the  constipation 

becomes  secondary  and  a  water  enema 
should  be  administered  every  day  if  neces- 
sary rather  than  stop  boiling  the  milk. 

(8)  Cathartics. 

(a)  Orange  juice  (small  quantities  at  first)   or 

scraped  raw  fruits  in  infants  over  six 
months  of  age. 

(b)  If  dietetic  measures  fail,  milk  of  magnesia 

is  the  mildest  laxative  to  use. 

(9)  Habit.   Accustom  the  infant  to  use  the  vessel  at  regu- 

lar intervals. 
(10)  Organic  lesions. 

(a)  Fissures  may  be  treated  with  a  stick  of  silver 

nitrate  once  in  three  or  four  days. 

(b)  An  abnormally  small  anus  may  be  gently 

stretched  day  by  day. 


SYNOPSIS  OF  TEXT  15 

VOMITING 
ACUTE  VOMITING 

Causes : 

(1)  Acute  indigestion. 

(2)  Infectious  gastro-enteritis. 

(3)  Miscellaneous  causes:  General  infectious  diseases 

such  as  pneumonia,  acute  exanthema,  etc.,  peri- 
tonitis, intestinal  obstruction,  nephritis,  cerebral 
vomiting  from  meningitis,  brain  tumor,  etc.,  drugs 
and  poisons. 
Treatment : 

(a)  Stop  food  and  water. 

(b)  Empty  the  bowels. 

(c)  Wash  out  the  stomach. 

(d)  Give  sodium  bicarbonate  by  mouth. 

(e)  Administer  sedatives. 

HABITUAL,    VOMITING 

Causes : 

(1)  Errors  in  the  details  of  administering  the  food. 

(a)  Too  rapid  feeding. 

(b)  Too  slow  feeding. 

(c)  Feeding  in  a  reclining  position  and  leaving 

the  infant  to  take  the  bottle  alone. 

(d)  Not  allowing  the  air  (swallowed  during  the 

nursing)  to  be  eructated  before  the  feeding 
is  completed  by  occasionally  holding  the  in- 
fant in  an  upright  position. 

(e)  Too  long  a  nipple,  which  gags  the  infant. 

(f)  Tossing  the  infant  about  or  handling  it  too 

soon  after  feeding. 

(g)  Tight  belly-band  and  clothing. 

(fat. 

(2)  Indigestion  fromrur^:dg 

(.  starch. 


16  SIMPLIFIED  INFANT  FEEDING 

Treatment : 

(a)  Feed  one-third  milk  and  two-thirds  water 

boiled  together,  with  no  sugar  or  a  very 
small  amount  of  sugar.  Gradually  increase 
to  half  and  half  and  add  sugar. 

(b)  Use  boiled  skimmed  milk  without  sugar  when 

case  is  not  controlled  by  treatment  (a). 

(3)  Overfeeding  in  quantity. 

The  normal  quantity  of  food  given  at  each  feeding 
should  be  one  or  two  ounces  more  than  the  number 
of  months  of  the  infant's  age,  with  a  maximum  of 
8  oz.  and  a  minimum  of  3  or  4  oz.,  while  the  under- 
sized infant  can  take  only  one  ounce  for  each  month 
of  its  age. 

In  infants  who  are  vomiting,  the  bulk  of  the  food 
taken  at  each  feeding  should  be  reduced  even  if  it 
involves  giving  a  stronger  food  in  order  to  supply 
the  caloric  needs. 

(4)  Organic  causes:  Pyloric  stenosis,  dilatation  of  the 

stomach,  gastroptosis. 

(5)  Hypertonic  (symptoms  which  are  cured  by  atropin) : 

(1)  Vomiting.  (4)  Constipation. 

(2)  Crying.  (5)  Cold  extremities. 

(3)  Insomnia.  (6)  Underweight. 

LOSS  OF  APPETITE 

Causes : 

(1)  Wrong  feeding  or  overfeeding. 

(2)  Limited  digestive  capacity.    (Babies  having  a  nar- 

row margin  between  their  "digestive  capacity  and 
the  amount  of  food  they  need  to  make  a  gain  in 
weight  when  properly  fed.) 

(3)  Inanition.     (Too  weak  to  take  food.) 

(4)  Sore  mouth  or  throat  or  some  other  pathological 

condition  which  makes  it  difficult  or  painful  for1 
the  infant  to  swallow. 


SYNOPSIS  OF  TEXT  17 

Treatment : 

(a)  Feed  one- third  milk,  two-thirds  water,  without  sugar 

(one-half  milk,  one-half  water  for  the  older,  larger 
infants). 

(b)  Lengthen  the  intervals  between  feedings  for  the 

older,  larger  infants. 

(c)  Use  a  nipple  with  a  very  large  hole  for  the  weak 

infants. 

(d)  Administer  strychnia,  gr.  1/soo  to  Viso  every  six 

hours,  before  a  feeding. 

(e)  Feed  by  gavage  as  a  last  resort. 

BREAST-FEEDING 
SYMPTOMS  INDICATIVE  OF  SUCCESSFUL  BBEAST-FEEDINO 

1.  The  infant  gains  six  or  eight  ounces  a  week  the  first  six 
months  and  after  that  from  three  to  six  ounces  a  week. 

2.  It  falls  asleep  as  soon  as  fed  or  while  feeding  and 
sleeps  twenty  hours  out  of  every  twenty-four  up  to  the  sixth 
month  of  age. 

3.  It  does  not  cry  more  than  one  hour  a  day. 

4.  It  has  from  one  to  three  normal  stools  a  day  and  no 
vomiting  or  gas. 

SYMPTOMS   INDICATIVE  OF   UNSUCCESSFUL  BREAST-FEEDING 

1.  The  infant  loses  in  weight,  ceases  to  gain  or  gains 
insufficiently. 

2.  It  remains  too  long  at  the  breast. 

3.  It  cries  or  frets  while  nursing. 

4.  It  cries  when  taken  from  the  breast. 

5.  It  has  abnormal  stools. 

6.  It  has  extreme  vomiting  which  can  be  definitely  attrib- 
uted to  the  breast  milk.     (All  the  above  symptoms  are  not 
invariably  present.) 

2 


18  SIMPLIFIED  INFANT  FEEDING 

CONDITIONS  UNDEB  WHICH  BREAST-FEEDINGS  SHOULD  BE 
CONTINUED  EXCLUSIVELY 

1.  Where  the  infant  is  normal  and  doing  well  upon  the 
breast. 

2.  Where  the  infant  is  not  doing  well  and  the  condition 
can  be  accounted  for  by  errors  in  the  management  of  the 
mother  or  infant,  or  by  the  health  of  the  mother. 

ERRORS  TO  BE  CORRECTED  IN  THE  MANAGEMENT  OF  THE 
MOTHER  OR  INFANT 

1.  Regulation  of  the  mother's  diet. 

2.  Improving,  if  necessary,  the  mother's  appetite. 

3.  Regulation  of  the  mother's  bowels. 

4.  Regulation  of  other  hygienic  details,  such  as  exercise, 
sleep  and  mental  quiet. 

5.  Remedying  any  actual  disease  of  the  mother,  such  as 
anemia,  etc. 

6.  Regulation  of  feeding  times  and  intervals. 

7.  Correcting  any  errors  in  the  detail  of  giving  the 
breast. 

8.  Remedying  any  defects  in  the  hygienic  surroundings 
or  management  of  the  infant. 

BREAST-FED,  NEW-BORN  INFANTS 

After  the  first  two  or  three  days  (during  which  time  an 
infant  may  be  fed  every  four  hours)  the  three-hour  interval 
should  be  used,  seven  feedings  in  twenty-four  hours. 

INDIGESTION  IN  NURSING  INFANTS  WHO  ARE  GAINING  WELL 

IN  WEIGHT 

1.  Do  not  stop  breast  for  indigestion. 

2.  Diminish  the  infant's  food  supply  by 

a.  Limiting  mother's  diet: 

(1)  Stop  large  quantities  of  liquid  nourish- 
ment between  meals. 


SYNOPSIS  OF  TEXT  19 

(2)  Stop  highly  flavored  fruits  or  vegetables, 

or  highly  seasoned  foods. 

(3)  Stop  alcohol,  candy,  and  rich  desserts. 

b.  Shorten  infant's  feeding  time  to  five  minutes 
once  in  three  hours,  six  or  seven  feedings  in 
twenty-four  hours.  (Gradually  lengthen  the 
feeding  times  up  to  the  infant's  capacity  after 
the  colic  has  ceased,) 

INDICATIONS  FOB  COMPLEMENTING  THE  BREAST  WITH  ARTIFICIAL 

FEEDINGS 

(Completing  Each  Feeding  with  the  Bottle) 

1.  Where  the  infant  does  not  gain  normally  in  weight 
after  a  thorough  trial  upon  the  breast  under  the  best  possible 

conditions. 

/ 

METHOD  OF  COMPLEMENTING  THE  BREAST  WITH  ARTIFICIAL 

FEEDINGS 

Give  five-  or  tftn-nriTmt.fi  feeding  from  the  breast,  com- 
pleting each  feeding  with  a  bottle.  Usually  use  one-third 
milk  and  two-thirds  water  to  start  with.  Gradually  increase 
to  half  milk  and  half  water,  and  if  the  bowels  are  constipated, 
add  one-quarter  ounce  of  sugar  in  the  twenty-four-hour 
mixture,  increasing  this  amount  as  the  weight  and  condition 
of  the  bowels  seem  to  warrant. 

INDICATIONS  FOR  SUPPLEMENTAL  FEEDINGS 

(Alternating  Bottle  Feedings  with  Breast  Feedings) 

1.  Where  the  infant  is  being  intentionally  weaned  from 
the  breast. 

2.  Where  the  mother  is  obliged  to  be  away  a  part  of  the 
day. 


20  SIMPLIFIED  INFANT  FEEDING 

CONTRA-INDICATIONS  FOB  BREAST-FEEDING 

(The  breast  must  never  be  discontinued  where  it  is  in 
any  way  possible  to  avoid  it.) 

1.  Where  the  infant  has  severe  prolonged  gastric  or 
intestinal  indigestion  associated  with  loss  in  weight  or  ces- 
sation of  gain. 

2.  When  at  two  previous  births  the  mother  has  been  un- 
successful in  nursing  the  infant  under  the  proper  conditions 
and  intelligent  care. 

3.  Where  the  mother  has  puerperal  convulsions. 

4.  Where  the  mother  is  pregnant. 

5.  Where  the  mother  has  some  prolonged  acute  infectious 
disease  as  typhoid  fever  or  pneumonia. 

6.  Where  the  mother  has  tuberculosis,  epilepsy,  nephritis, 
any  malignant  disease,  anaemia,  or  where  the  mother  or  the 
infant  has  contracted  syphilis  after  the  infant's  birth. 

CONDITIONS  UNDER  WHICH  THE  BREAST  SHOULD  BE  TEMPORARILY 

DISCONTINUED 

1.  In  acute  illness  of  the  mother. 

2.  In  selected  cases,  during  menstruation. 

3.  In  some  cases  of  acute  diarrhoea  in  the  infant. 

4.  In  some  cases  of  acute  vomiting  in  the  infant. 

WEANING,  EIGHT  TO  TEN  MONTHS  OF  AGE 

Wean,  if  possible,  directly  to  cup  and  spoon,  so  that  a 
second  weaning  from  the  bottle  is  not  necessary. 

Wean  gradually  by  substituting  one  artificial  feeding  at 
a  time  for  the  breast  feeding. 

Foods  to  give  while  weaning :  cereals,  whole  milk,  crack- 
ers, stale  bread,  baked  potato. 


SYNOPSIS  OF  TEXT  21 

DIARBHCEA   IN    BBEAST-FED   INFANTS 

Usual  Causes : 

1.  Overfeeding. 

2.  Changes  in  the  breast  milk. 

3.  An  acute  intestinal  indigestion  arising  from  supple- 

menting the  breast  with  other  foods. 

VOMITING  IN  BBEAST-FED  INFANTS 

Acute  Vomiting. 

Cause :  Acute  indigestion. 

Treatment :  Temporarily  stop  all  food  and  water ;  empty 
bowels,  institute  treatment  suggested  in  section  on 
"Vomiting  in  Bottle-fed  Infants." 
Habitual  Vomiting. 
Causes : 

1.  Errors  in  details  of  breast  feeding,  etc. 

2.  Too  rich  milk. 

3.  Organic  causes. 

Treatment:  Correct  errors  in  detail,  shorten  feeding 
time,  or  treat  for  organic  trouble. 

CONSTIPATION  IN  BBEAST-FED  INFANTS 

Causes : 

1.  Irregular  and  too  frequent  feedings. 

2.  Constipation  of  the  mother. 

3.  Insufficient  food. 

4.  Excessive  vomiting. 

5.  Abuse  of  cathartics. 


CHAPTER  II 

SOME  POINTS  ON  INFANTS  IN  GENERAL  WITH 
SPECIAL  REFERENCE  TO  BOTTLE-FED  BABIES 

To  attain  the  greatest  measure  of  success  in  feeding 
bottle-fed  infants,  one  must  pay  attention  not  only  to  the 
minutest  details  of  the  infant's  life,  but  also  to  the  most 
careful  carrying  out  of  all  directions  in  connection  with  it. 
The  author  frequently  hears  the  complaint  that  mothers  will 
not  follow  the  directions  given,  and  he  believes  that  when 
this  is  so,  the  trouble  often  lies  with  the  physician. 

HISTOBY  TAKING 

It  is  an  art  to  take  a  good  history.  The  very  fact  that  a 
thorough  history  is  taken,  showing  familiarity  with  all  the 
details  of  feeding,  inspires  confidence.  It  is  almost  impos- 
sible to  get  a  correct  idea  of  symptoms  and  existing  condi- 
tions from  the  voluntary  information  of  any  mother,  and  it 
is  left  for  the  physician  to  tactfully  obtain  from  her  the 
information  necessary  for  the  successful  treatment  of  his 
case. 

He  may  begin  by  getting  information  as  to  the  number 
of  previous  children;  how  many  are  living,  and  how  many 
have  died.  The  history  of  a  number  of  deaths  in  the  family 
during  the  bottle  period  has  a  direct  bearing  upon  the  prog- 
nosis of  the  individual  case,  the  infant  to  be  treated 
very  probably  not  having  proper  resistance  nor  digestive 
capacity. 

Then  comes  the  question  of  how  long  the  infant  has  been 

breast  fed,  and  with  what  success.    An  infant  that  has  had 

a  good  start  upon  the  breast,  even  if  it  were  only  for  one 

or  two  months,  will  not  be  as  difficult  to  feed,  nor  to  treat, 

22 


BOTTLE-FED  BABIES  23 

when  gastro-intestinal  disturbances  occur,  as  one  who  has 
never  had  any  breast  milk.  But,  on  the  other  hand,  a  pro- 
longed unsuccessful  attempt  at  giving  the  breast  may  have 
exactly  the  opposite  effect,  in  weakening  the  infant  and 
lowering  its  digestive  capacity. 

Food  Previously  Taken. — A  knowledge  of  the  composition 
of  the  previous  food  is  of  the  utmost  importance  in  prescrib- 
ing a  new  food  for  an  infant.  If  food  containing  cow's  milk 
has  never  been  given,  it  is  necessary  to  guard  against  giving 
too  large  an  amount  of  it  at  first,  and  against  too  rapidly 
increasing  the  amount.  The  same  is.  true  of  an  infant  who 
has  never  had  any  sugar. 

If  a  proprietary  food  has  been  used,  one  must  know  what 
that  proprietary  food  contains,  in  order  not  to  repeat  the 
error  that  has  already  caused  digestive  disturbances  or 
malnutrition.  To  get  the  important  information  relating 
to  previous  foods,  it  is  generally  necessary  to  ask  many 
questions.  To  the  first  question,  "What  are  you  feeding 
your  baby?"  the  answer  usually  will  be,  " Cow's  milk,"  or 
' '  Barley  gruel, ' '  or  such  and  such  a  proprietary  food.  It  is 
then  advisable  to  say,  "Tell  me  just  how  you  make  this 
food. "  It  is  an  exceptional  mother  who  will  even  then  ex- 
plain to  you  each  detail  of  making  the  food,  and  the  exact 
quantity  of  each  ingredient.  When  told  that  milk  and  water 
are  used,  the  physician  must  ascertain  how  many  ounces  of 
milk  and  how  many  ounces  of  water,  and  whether  or  not 
they  have  been  boiled  together  or  separately  or  not  at  all. 

Although  it  is  one  of  the  most  important  ingredients  of 
the  food,  in  the  vast  majority  of  cases  the  mother  neglects 
to  make  any  mention  of  the  sugar.  For  this  reason,  the  ques- 
tion must  always  be  asked,  "Are  you  using  any  sugar,  and 
if  so,  how  much  and  what  kind?" 

The  Number  of  Feedings,  Intervals,  and  Quantity  of  Food 
Taken. — After  having  ascertained  the  kind  of  food  being 
taken,  the  next  step  is  to  find  out  the  quantity  given  at  each 


24  SIMPLIFIED  INFANT  FEEDING 

feeding  and  the  intervals  at  which  the  infant  is  being  fed, 
as  well  as  the  number  of  feedings  during  the  night  and  day. 
It  is  impossible  to  tell  whether  an  infant  is  overfed  or  under- 
fed unless  the  quantity  of  food  taken  during  each  twenty- 
four-hour  period  is  known.  The  quantity  of  each  ingredient 
may  be  correct,  and  yet,  if  all  of  the  food  is  not  taken, 
underfeeding  is  the  result.  If  the  infant  has  been  fed  irregu- 
larly or  the  quantity  has  been  given  by ' '  guess, "  it  is  difficult 
to  obtain  very  exact  data.  In  such  cases  it  is  often  possible 
to  find  out  how  many  bottles  an  infant  is  getting  a  day  by 
reviewing  the  events  of  the  present  day  or  the  previous 
day  from  morning  until  night,  and  fixing  the  time  of  each 
feeding.  The  number  of  feedings,  multiplied  by  the  quantity 
taken  at  each  feeding,  will  give  the  total  twenty-four-hour 
amount  of  food,  which  should  be  compared  with  the  quantity 
that  is  said  to  have  been  made  up  for  the  day.  By  cross- 
questioning,  it  is  frequently  found  that  all  the  food  that  is 
made  up  is  not  being  taken  by  the  infant.  Again,  the  amount 
of  food  which  the  mother  has  described  may  not  be  the  cor- 
rect quantity,  because  she  has  prepared  the  food  more  than 
once  during  the  day.  The  question,  "What  time  do  you 
make  your  food  ? ' '  will  help  to  make  this  information  more 
accurate. 

The  Bowels. — Having  ascertained  all  the  details  of  the 
composition  and  quantity  of  the  food,  the  intervals  and  num- 
ber of  feedings,  it  is  then  well  to  inquire  about  the  bowels. 
To  the  question,  "How  are  the  bowels!'*  very  little  infor- 
mation is  elicited,  for  the  answer  will  usually  be,  "All  right, ' ' 
or  *  *  Very  bad, ' '  both  of  which  are  unreliable  for  the  reason 
that  the  mother's  opinion  may  differ  from  yours.  It  is 
therefore  well  to  open  the  discussion  of  the  condition  of  the 
bowels  by  asking  the  question,  "How  many  stools  does  your 
baby  have  a  day?"  after  which  inquiries  as  to  the  color  and 
consistency  must  be  made:  whether  mucus,  curds  or  blood 
are  seen,  and  never  omitting  to  ask  whether  cathartics  are 


BOTTLE-FED  BABIES  25 

being  used  or  not.  The  stools  should  then  be  carefully  in- 
spected. If  none  have  been  saved  for  this  purpose,  direc- 
tions should  be  given  to  have  them  saved  in  the  future. 
(See  Stools,  page  8&9i  (ft 

Vomiting. — We  must  now  consider  the  question  of  vomit- 
ing. To  the  question,  "Does  your  baby  vomit?"  the  answer 
is  almost  invariably  "Yes."  This,  too,  is  probably  very 
unreliable  information,  as  it  may  mean  that  only  a  mouthful 
is  spit  up  immediately  after  a  feeding,  perhaps  because  of 
the  air  swallowed  during  the  nursing.  If  this  is  the  extent 
of  the  vomiting,  it  should  be  recorded  as  none.  If  it  is 
decided  that  the  vomiting  is  extensive  enough  to  have  a  bear- 
ing upon  the  case,  care  is  to  be  taken  to  find  out  the  quantity 
vomited.  It  is  important  to  find  out  whether  the  vomiting 
occurs  immediately  after  feedings,  throughout  the  inter- 
vals, or  just  before  a  feeding  is  due.  It  is  also  well  to  find 
out  whether  or  not  it  is  projectile  in  character.  (See 
Vomiting,  page  178.) 

The  Appetite. — The  appetite  is  the  next  factor  to  be  con- 
sidered in  the  history.  ' '  Does  your  baby  take  all  the  food 
given  it  at  each  feeding,  and  if  not,  how  much  is  left  and 
at  how  many  feedings  during  the  day  does  this  occur?" 
An  infant  should  readily  take  all  the  food  offered  if  the 
food  is  a  proper  one  and  if  all  the  details  of  administering 
it  are  carefully  followed  out.  A  mother  will  often  tell  you 
that  the  baby  is  not  satisfied  with  its  food.  It  then  becomes 
necessary  to  find  out  whether  the  infant  cries  before  a  feed- 
ing is  due,  or  when  a  feeding  is  finished,  as  either  may  indi- 
cate hunger.  (See  Loss  of  Appetite,  page  200.) 

Sleep. — Ascertain  next  the  amount  of  time  spent  in  sleep 
during  the  day  and  night.  Lack  of  sleep  may  be  indicative 
either  of  hunger  or  of  indigestion.  During  the  first  weeks 
of  life  an  infant  should  sleep  almost  all  day,  except  when 
nursing  or  while  being  bathed.  After  three  months  of  age, 
a  healthy  infant  will  sleep  at  least  twenty  hours  out  of  the 


26  SIMPLIFIED  INFANT  FEEDING 

twenty-four,  and  beyond  six  months,  sixteen  to  eighteen 
hours.  It  should  be  wakened  for  each  feeding  in  order  to 
establish  regular  habits.  As  soon  as  a  normal  infant  is  fed, 
it  will  fall  asleep  again,  so  that  it  does  no  harm  to  awaken  it. 

The  Weight. — The  next  step  is  to  weigh  the  infant,  for 
without  the  exact  weight  to  begin  with,  it  is  impossible  to 
feed  a  sick  baby.  It  is  impossible,  too,  to  gauge  the  required 
quantity  of  the  various  ingredients  of  the  food  without  the 
exact  weight.  The  physician  who  intends  to  do  much  work 
among  infants  must  have  an  accurate  pair  of  scales  in  his 
office.  An  infant  who  is  not  making  a  normal  progress  and 
who  is  seen  in  the  home  must  be  weighed  there  and  scales 
must  be  especially  provided  for  this  purpose.  If  the  parents 
are  taught  the  importance  of  knowing  the  baby's  weight, 
they  will  usually  be  only  too  glad  to  cooperate  in  the  matter 
of  supplying  the  scales.  The  dial  or  spring  scales,  such  as 
are  ordinarily  sold  for  weighing  babies,  are  practically  use- 
less, for  when  the  baby  kicks,  the  dial  bobs  about  to  such  an 
extent  that  an  accurate  reading  is  almost  impossible. 

The  infant  should  be  weighed  naked  and  the  weight 
accurately  recorded.  Weekly  weighings  are  advisable. 

The  normal  infant  doubles  its  birth  weight  in  six  months, 
and  trebles  it  in  one  year.  That  is,  an  infant  weighing  7% 
pounds  at  birth  should  weigh  15  pounds  at  six  months  of 
age  and  22  pounds  at  one  year.  There  is  an  initial  loss  in 
weight  during  the  first  three  to  five  days  after  birth  which 
should  not  be  greater  than  eight  ounces.  This  loss  should 
be  regained  by  the  end  of  the  second  week.  After  this,  there 
should  be  a  steady  gain  of  about  one  ounce  a  day  or  from 
six  to  eight  ounces  a  week,  up  to  the  sixth  month  of  age. 
This,  however,  may  not  always  be  continuous,  more  being 
gained  one  week  and  less  another.  After  the  sixth  month, 
a  gain  of  four  or  five  ounces  a  week  is  all  that  may  be 
expected. 


BOTTLE-FED  BABIES  27 

It  is  not  advisable  and  I  never  allow  a  mother  to  weigh 
her  baby  every  day,  as  she  will  usually  worry  on  the  days 
that  do  not  show  a  gain  in  the  baby's  weight. 

PHYSICAL  EXAMINATION 

Having  finished  with  the  infant's  history  to  date,  the 
physician  is  prepared  to  begin  upon  his  physical  examina- 
tion. He  may  observe  first,  the  color. 

Color. — Infants  that  have  been  difficult  to  feed  and  have 
had  much  indigestion  or  have  been  undernourished  over  a 
long  period  of  time  are  apt  to  be  pale.  A  marked  pallor  is 
almost  universally  observable  in  atrophic,  emaciated  babies 
(marasmus).  Many  fat  and  seemingly  well-nourished  in- 
fants, during  the  latter  half  of  the  first  year,  are  pale,  and 
condensed  milk  infants  are  notoriously  white  and  fat. 

Skin. — Much  valuable  information  may  be  gained  by  a 
careful  inspection  of  the  skin  over  the  entire  body.  A  skin 
inelastic  and  wrinkled  (so  that  when  one  wrinkles  it  up  the 
wrinkles  remain  for  several  seconds  before  smoothing  them- 
selves out  again)  is  characteristic  of  the  emaciated  and 
atrophic  infant.  This  sluggish  condition  of  the  skin  is 
almost  always  of  bad  import,  and  indicates  that  the  other 
organs,  particularly  those  of  the  gastro-intestinal  tract,  are 
probably  equally  as  sluggish. 

Lesser  degrees  of  nutritional  disturbances  are  manifested 
in  the  skin  by  a  certain  roughness  and  scaling,  red  papules 
scattered  over  the  body,  and  a  susceptibility  to  eczema, 
intertrigo,  furunculosis,  or  prickly  heat.  Another  significant 
appearance  of  the  skin  is  seen  in  infants  who  have  become 
rapidly  emaciated  from  a  severe  enteritis  or  other  acute 
illness.  This  condition  manifests  itself  in  a  different  form 
of  wrinkling  than  that  of  the  atrophic  infant,  because  the 
fat  layer  is  not  entirely  gone  from  underneath  the  skin, 
the  lack  of  tone  and  inelasticity  in  this  case  being  due  to 
the  sudden  loss  of  fluids  from  the  body  and  perhaps,  in  addi- 


28  SIMPLIFIED  INFANT  FEEDING 

tion,  to  severe  toxaemia.    This  condition  of  the  skin,  too,  is 
almost  always  of  bad  import. 

One  of  the  first  manifestations  of  the  improvement  in  all 
such  cases  is  the  healthy  smoothness  and  glossiness  of  the 
skin,  which  appears  as  soon  as  the  weight  increases  and  the 
digestive  disturbances  are  overcome. 

Development. — Next  comes  the  infant's  development.  In- 
fants who  have  done  badly  are  usually  small,  often  being 
several  inches  below  the  normal;  they  are  usually  under 
weight,  as  shown  by  the  scales. 

The  classification  that  is  often  used  in  referring  to  an 
infant's  condition  makes  a  distinction  between  fat,  well 
nourished,  moderately  well  nourished,  poorly  nourished  or 
emaciated.  This  is  a  rough  way  of  expressing  the  examiner's 
opinion  of  the  infant's  nutrition,  and  is  on  the  whole  a  very 
useful  classification.  The  moderately  well-nourished  infant 
is  one  that  is  a  little  below  the  normal  standard.  The  poorly- 
nourished  infant  is  thin,  while  the  emaciated  infant  has  lost 
all  of  the  fat  layer,  its  ribs  stick  out,  and  the  joints  are 
prominent. 

The  term  * '  atrophy, ' '  called  by  Finkelstein  * '  decomposi- 
tion," and  formerly  known  as  marasmus,  applies  to  the 
drying  up  of  the  whole  body,  with  loss  of  power  to  absorb 
and  assimilate  food.  A  typical  senile  facial  expression  is 
characteristic  of  this  latter  class  of  infants. 

Poor  musculature  is  a  term  indicative  of  a  flabby  con- 
dition of  the  muscles,  which  can  be  readily  seen  and  appre- 
ciated on  feeling  the  arms  and  legs. 

Infants  who  have  had  digestive  disturbances,  or  have 
been  improperly  fed,  or  who  for  any  reason  have  not  pros- 
pered are  usually  undersized  or  small  in  stature.  It  is  not 
uncommon  to  see  an  infant  of  six  or  seven  months  that  is 
only  as  large  as  a  two-months-old  baby  should  be,  or  an 
infant  of  ten  months  that  is  the  size  of  the  normal  four- 
months-old  baby. 

Temperature. — The  taking  of  the  temperature  is  of  great 


BOTTLE-FED  BABIES  29 

importance  and  is  too  often  neglected.  An  emaciated  or 
marasmic  infant  will  frequently  run  a  subnormal  tempera- 
ture, which  is  strongly  indicative  of  its  condition  and  points 
definitely  to  the  fact  that  the  infant  should  not  be  exposed 
to  sudden  changes  in  the  temperature  and  should  be  kept 
warm.  Starvation,  particularly  in  new-born  and  very  young 
infants,  will  often  cause  a  temperature  of  101°  or  102°  F. 
The  differential  diagnosis  between  an  infectious  diarrhoea 
and  a  bad  case  of  intestinal  indigestion  often  rests  upon  the 
fever,  a  high  temperature  usually  being  present  in  an  infec- 
tious diarrhoea  and  no  temperature  or  one  of  very  slight 
degree  in  intestinal  indigestion  (except  when  acute). 

Mouth. — An  examination  of  the  mouth  is  most  important. 
All  forms  of  thrush  and  stomatitis  find  a  fertile  field  in  cases 
of  malnutrition.  A  refusal  to  take  food  may  be  due  to  a  sore 
and  inflamed  condition  of  the  mouth.  An  extremely  red, 
irritated  appearance  of  the  inside  of  the  mouth  and  tongue, 
called  a  beefy  tongue,  is  often  found  in  subnormal  infants 
and  in  those  having  various  digestive  disturbances,  and  is 
indicative  of  their  condition.  A  coated  tongue  is  just  as 
important  a  sign  in  the  infant  as  it  is  in  the  adult,  yet  many 
physicians  who  would  never  think  of  neglecting  to  look  at 
the  tongue  of  an  adult  patient  seldom  examine  the  tongues 
of  their  feeding  cases.  A  coated  tongue  is  often  the  first 
manifestation  of  indigestion,  before  vomiting  or  intestinal 
indigestion  begins,  and  a  clean  tongue,  in  cases  where  the 
history  of  vomiting  is  given,  gives  rise  to  the  suspicion  that 
the  mother  is  exaggerating  this  symptom  or  that  the  vomit- 
ing is  due  to  some  error  in  administering  the  food,  rather 
than  to  indigestion. 

Teething. — Teething  infants  are  most  difficult  to  feed, 
particularly  if  they  have  always  been  artificially  fed  and  if 
the  food  has  not  been  properly  prepared  and  administered. 

In  spite  of  the  difference  of  opinion  regarding  the  in- 
fluence of  the  teething  process  upon  the  infant's  digestive 
apparatus,  the  author  believes  that  digestive  disturbances 


30  SIMPLIFIED  INFANT  FEEDING 

are  more  easily  acquired  at  the  time  of  the  eruption  of  the 
teeth.  Diarrhoea  is  probably  not  caused  directly  by  the 
teething  process,  but  infants  who  have  a  great  deal  of  local 
irritation  in  the  gums  and  a  consequent  loss  of  sleep  have, 
therefore,  a  lowered  digestive  capacity.  The  appetite  is  im- 
paired, and  a  diarrhoea  acquired  at  this  time  is  difficult 
to  combat. 

Facial  Expression. — It  is  well  to  observe  here  the  infant's 
facial  expression,  for  in  all  diseases  of  infancy  much  infor- 
mation may  be  gained  in  this  way.  It  is  often  possible  to  tell 
at  a  glance  that  an  infant  is  having  abdominal  distress  by 
the  characteristic  expression  of  its  face.  One  is  able,  also, 
to  recognize  an  infant  suffering  with  severe  acute  infectious 
diarrhoea,  dysentery  and  intoxication  by  the  sunken  and  half- 
closed  eyes,  open  mouth,  and  general  appearance  of  stupor. 
There  is  also  the  listless,  lifeless  expression  of  the  infant 
who  has  been  underfed  for  a  long  period  of  time  and  the 
senile  expression  of  the  atrophic  infant  to  be  noted. 

Heart  and  Lungs. — The  heart  and  lungs  must  be  exam- 
ined to  make  sure  that  there  is  no  diseased  condition  of 
these  organs. 

Abdomen. — Abdominal  distention  is  a  frequent  accom- 
paniment of  intestinal  indigestion,  malnutrition,  and  rickets. 
Infants  that  have  been  improperly  fed  come  to  the  physician 
with  a  marked  abdominal  distention,  and  one  of  the  first 
indications  of  the  infant's  improvement  under  the  proper 
dietetic  treatment  is  a  decrease  in  this  distention,  provided 
it  is  not  due  to  some  organic  disease  of  the  abdomen.  A 
sunken  abdomen  is  usually  an  indication  of  a  severe  or  pro- 
longed diarrhoea,  or  a  long  period  of  underfeeding.  The 
abdominal  tone  offers  valuable  information.  Upon  pal- 
pation, the  healthy  muscular  resistance  of  the  abdomen  of 
the  normal  infant  is  in  great  contrast  to  the  soft,  doughy 
feel  of  the  abdomen  when  nutritional  disturbances  are  pres- 
ent. It  is:  well  to  become  familiar  with  this  peculiar  feel 
in  order  readily  to  distinguish  the  various  grades  between. 


BOTTLE-FED  BABIES  31 

the  two.  The  greater  the  loss  of  abdominal  tone,  the  worse 
is  the  prognosis  in  the  individual  case.  An  examination 
should  be  made  for  enlarged  spleen  and  liver,  abnormal 
masses  and  fluid  in  order  to  rule  out  other  abdominal  dis- 
eases in  the  final  diagnosis. 

Evidences  of  Rickets. — An  infant  suffering  from  rickets  is 
difficult  to  treat.  He  gains  more  slowly  in  weight  and 
strength  and  has  less  power  to  resist  intercurrent  affections. 

An  abnormally  large  head  and  f  ontanel,  delayed  closure 
of  the  fontanel  or  sutures,  and  bald  spots  on  the  back  of  the 
head  where  the  brittle  hair  has  been  rubbed  off  are  all  indica- 
tive of  rickets. 

Beading,  which  consists  of  an  enlargement  at  the  costo- 
chondral  articulation  of  each  rib,  pigeon-breast,  flaring  of 
the  ribs,  which  gives  a  bell-shaped  chest,  and  Harrison 's 
groove  (a  depression  around  the  chest  at  the  insertion  of 
the  diaphragm)  are  further  evidences  of  rickets  observable 
in  the  bones  of  the  chest.  In  some  emaciated,  rhachitic  in- 
fants the  ribs  are  so  soft  that  the  chest  sinks  in  instead  of 
expanding  at  each  inspiration. 


Having  diagnosed  the  case  and  decided  upon  the  exact 
composition  of  the  food  needed  and  the  intervals  and  time 
of  feeding,  the  directions  should  be  plainly  written  for  the 
mother  so  that  she  may  have  them  for  future  reference. 
By  so  doing,  many  mistakes  are  avoided.  The  mother  may 
be  confused  and  possibly  ill  at  ease,  and  consequently  by 
the  time  she  arrives  home  has  forgotten  most  of  the  oral 
directions  that  have  been  given  her.  The  writing  of  such 
directions  takes  very  little  more  time  than  it  does  to  explain 
them  orally,  and  both  may  be  done  at  the  same  time,  once 
the  habit  is  acquired. 

The  quantity  of  milk,  the  quantity  of  water,  the  quantity 
of  sugar,  whether  the  milk  is  to  be  boiled  or  not,  and  the 
exact  method  of  preparing  the  food  should  be  stated  clearly. 


32  SIMPLIFIED  INFANT  FEEDING 

The  following  printed  blank  is  used  by  the  author  and  saves 
much  time  and  annoyance : 

Milt  ounces 

Water ounces 

Sugar   level  tablespoon! uls 

Divide  evenly  into bottles. 

Feed  at    ,    ,    A.M.;     ,    ,  P.M.    ,    ,    A.M. 

The  above  food  is  enough  for  twenty- four  hours:  no  more  should  be  made. 
Always  make  the  food  at  the  same  time  each  day. 

The  amount  has  been  carefully  calculated  and  the  baby  should  take  it  all. 
Always  use  a  fresh  unopened  bottle  of  milk.     Pour  the  milk  into  a  clean 
pitcher,  pour  it  back  into  the  bottle  to  mix  the  cream  through  it  thoroughly. 
Do  not  boil  the  food  unless  directed  to  do  so  here. 

BOIL:    DO  NOT  BOIL 

When  the  milk  is  to  be  boiled  it  should  be  done  in  the  following  manner : 
Measure  out  the  required  number  of  ounces  of  water,  put  it  into  a  saucepan, 
and  bring  it  to  an  active  boil.  While  boiling,  pour  in  the  required  number  of 
ounces  of  milk  and  bring  to  a  boil  as  rapidly  as  possible,  stirring  vigorously 
all  the  time  so  that  a  scum  will  not  form  upon  the  top.  Boil  actively  for  three 
minutes  after  it  has  once  come  to  a  boil. 

Do  not  add  the  sugar  until  the  food  is  taken  off  the  stove. 

The  sugar  is  to  be  measured  with  the  average  sized  tablespoon  and 
levelled  with  a  knife. 

Pour  immediately  into  clean  feeding  bottles,  using  as  many  bottles  as  there 
are  to  be  feedings  in  twenty-four  hours,  each  bottle  to  contain  the  required 
number  of  ounces  for  one  feeding  when  the  whole  is  divided  evenly  among  them. 
Stop  up  the  bottles  with  a  clean  piece  of  absorbent  cotton.  Place  them  in 
the  bottle  rack  and  cool  as  quickly  as  possible,  in  cold  running  water  in  the 
summer  time,  and  out  of  the  window  in  the  winter  time.  It  should  take  no 
more  than  ten  minutes  to  get  the  bottles  very  cold.  Place  directly  upon  the 
ice  until  used.  At  each  feeding-time  place  a  bottle  in  hot  water  or  in  a 
bottle  warmer  and  heat  to  blood  heat,  testing  the  temperature  on  your  bare 
forearm.  Never1  heat  the  bottle  before  it  is  time  to  feed  the  baby. 

Bottle  babies  over  two  months  of  age  must  always  have  orange  juice. 
Begin  with  a  teaspoonful  once  a  day,  one  hour  before  a  feeding.  As  the  baby 
gets  older  increase  the  orange  juice  a  teaspoonful  at  a  time,  up  to  the  juice 
of  a  half  or  a  whole  orange,  once  a  day,  an  hour  before  a  feeding. 

If  not  directed  to  boil  the  milk,  boil  the  water  alone,  take  it  off  the 
gtove,  measure  out  the  proper  quantity  and  add  the  sugar  while  it  is  hot.  Allow 
it  to  become  ice-cold  before  adding  the  milk,  which  should  also  be  ice-cold. 

Feed  at  the  same  time  each  day,  exactly  upon  the  hours  stated  above, 
awakening  the  baby  if  asleep,  until  accustomed  to  regular  hours. 

Hold  the  baby  in  your  lap  while  feeding,  sitting  up  in  the  same  position 
as  though  he  were  taking  the  breast.  It  should  take  fifteen  or  twenty  min- 


BOTTLE-FED  BABIES  33 

utes  to  take  the  bottle.  If  taken  quicker  than  that,  a  nipple  with  a  smaller 
hole  should  be  used.  Do  not  keep  taking  the  nipple  out  of  the  mouth  to 
lengthen  the  time  of  a  feeding.  If  the  feeding  takes  much  longer  than  fifteen 
minutes,  get  a  nipple  with  a  larger  hole.  If  the  baby  does  not  take  all  the 
food  in  twenty  minutes,  when  the  hole  is  large  enough,  throw  the  remainder 
away  and  wait  until  the  next  feeding-time  before  feeding  again. 

Immediately  after  a  feeding  is  taken,  scrub  the  bottle  with  a  bottle  brush 
and  soap.  Rinse  out  the  soap  and  put  a  heaping  teaspoonful  of  borax  into  the  ; 
bottle,  fill  half  full  of  water  and  shake  until  the  borax  is  dissolved.  Then  fill 
the  bottle  brimming  full  of  water  and  allow  it  to  stand  until  the  food  is  mixed 
the  next  morning,  when  the  borax  water  is  poured  out,  the  bottle  rinsed  and 
turned  upside  down  to  drain  while  the  food  is  being  made.  The  nipples  should 
be  cleaned  out  immediately  with  dry  borax  and  placed  in  half  a  glass  of  water 
with  a  heaping  teaspoonful  of  borax  in  it,  until  used  again. 

The  following  utensils  should  be  purchased  and  kept  for  the  baby's  use 
only: — 8  nursing  bottles  (Walker-Gordon  bottles  preferred),  with  small  necks 
and  bottoms  rounded  on  the  inside.  At  least  three  nipples  (Davidson's  or 
Anti-Colic).  A  wire  bottle  rack  holding  six  or  seven  bottles.  A  cheap,  blown 
glass  graduate  (measuring  glass),  holding  sixteen  ounces.  A  glass  funnel 
which  fits  nicely  into  the  bottles.  A  deep  saucepan,  the  bottom  of  which  is 
no  more  than  six  inches  in  diameter,  so  that  the  milk  will  not  boil  away  too 
much.  An  enamel  or  china  pitcher  that  pours  well.  A  tablespoon,  regulation 
size,  the  bowl  of  which  is  2%  inches  long  and  1%  inches  wide. 

Do  not  be  disturbed  if  the  baby  vomits  a  few  mouthfuls  after  a  feeding; 
even  normal  breast-fed  babies  do  this. 

Do  not  under  any  circumstances  give  castor  oil,  castoria,  milk  of  mag- 
nesia or  any  other  cathartics,  unless  the  baby  is  suddenly  taken  acutely  ill 
with  a  fever.  If  the  bowels  do  not  move  at  the  end  of  twenty-four  hours 
give  an  injection  of  plain  water  or  warm  sweet  oil,  using  a  baby  ball  syringe 
(sometimes  called  an  ear  syringe),  with  a  soft  rubber  tip.  When  oil  is  used 
1  ounce  is  sufficient.  It  should  be  allowed  to  stay  up  two  or  three  hours  if 
possible.  When  water  is  used  three  or  four  syringefuls  may  be  required  to 
bring  about  the  movement.  Constipation  is  not  harmful  to  bottle-fed  babies 
who  have  done  poorly,  but  is,  in  fact,  much  welcomed,  while  stools  which  are 
too  loose  are  very  injurious. 

ALWAYS  BBHTG  OXE  OB  TWO  STOOLS  AT  EACH  VISIT. 

The  food  for  twenty-four  hours  should  be  made  once  a 
day,  at  the  same  time  each  day,  and  as  soon  as  possible 
after  the  milk  comes  in  the  morning.  The  milk  should  never 
be  allowed  to  stand  outside  the  door  where  there  is  an  early 
morning  delivery,  but  should  immediately  be  put  upon  ice 
until  the  food  is  made.  The  advantage  of  making  up  all  the 
food  for  the  day  at  the  same  time  is  obvious,  for,  by  so  doing, 
all  the  feedings  are  uniform  in  composition.  When  the  food 

3 


34  SIMPLIFIED  INFANT  FEEDING 

is  made,  the  entire  amount  should  be  divided  equally  into  the 
number  of  feedings  required,  one  bottle  for  each  feeding 
prescribed  in  the  twenty-four  hours.  When  this  detail  is 
painstakingly  carried  out,  the  food  is  as  clean  as  possible, 
since  it  has  been  put  into  sterile  bottles  and  nothing  has 
come  into  contact  with  it  before  it  is  taken.  By  this  means, 
it  is  also  easier  to  find  out  whether  all  the  food  is  taken,  by 
asking  if  there  is  any  left  over  in  the  bottle  after  any  of  the 
feedings,  or  if  there  are  any  bottles  left  over  in  the  morning 
when  the  new  feedings  are  made  up. 

BOTTLES,  NIIPPLES  AND  UTENSILS  FOR  MAKING  THE  FOOD 

The  Bottles. — The  best  bottles  are  those  that  are  round 
and  cylindrical  in  shape  and  have  a  narrow  neck  for  the 
attachment  of  the  nipple.  A  most  important  requirement 
of  a  bottle  is  that  it  have  no  corners  on  the  inside,  being 
rounded  both  at  the  bottom  and  at  the  top  where  the  neck 
begins,  which  enables  it  to  be  kept  thoroughly  clean.  Since 
there  should  be  as  many  bottles  as  there  are  feedings  in 
twenty-four  hours,  it  is  best  to  get  a  wire  bottle  rack  to  hold 
them  when  the  food  is  made  up  for  the  day. 

The  following  directions  should  be  given  the  mother :  As 
soon  as  the  baby  has  taken  his  feeding,  wash  out  the  bottle 
with  soap  or  washing  powder,  using  a  long-handled  bottle 
brush  to  get  it  scrupulously  clean.  Then  rinse  the  soap  out 
with  hot  water,  and  put  into  the  bottle  a  heaping  teaspoonful 
of  borax.  Some  warm  water  is  now  poured  in  and  the  bottle 
is  vigorously  shaken  until  all  the  borax  is  dissolved.  It  is 
then  filled  brimming  full  of  water  and  allowed  to  stand  full 
of  this  strong  borax  solution  (borax  is  a  stronger  and  better 
antiseptic  than  sodium  bicarbonate)  until  the  next  morning, 
when  the  feedings  are  made  up  for  the  day.  If  each  bottle 
is  treated  in  this  way,  we  have  in  the  morning  the  whole 
number  perfectly  clean  and  ready  to  be  filled  with  the  day's 
feedings  as  soon  as  the  borax  solution  has  been  poured  out 
and  the  bottles  rinsed  once  with  clear  water.  "With  this 


BOTTLE-FED  BABIES  35 

method  it  is  unnecessary  to  boil  the  bottles  each  day,  which 
is  a  great  saving  of  time  and  trouble.  The  bottles  should 
never  be  allowed  to  stand  unclean  or  filled  with  plain 
cold  water. 

The  nipples  are  also  important.  For  the  small  baby,  a 
nipple  that  is  not  too  large  nor  too  long  should  be  selected. 
Frequently,  a  long  nipple  will  gag  an  infant  and  may  be  the 
cause  of  vomiting  the  whole  feeding  just  as  it  is  being  fin- 
ished. It  is  often,  a  very  difficult  task  to  get  nipples  with 
holes  of  the  correct  size.  If  the  baby  gets  the  food  too  fast,  it 
may  cause  colic,  indigestion  or  vomiting;  therefore,  care 
should  be  taken  in  the  selection  of  a  nipple  with  one  hole  in  it 
which  will  be  small  enough  so  that  the  feeding  cannot  be 
taken  in  less  than  twenty  minutes.  It  is  well  to  have  two  or 
three  nipples  on  hand.  When  new,  they  should  be  boiled 
once.  As  soon  as  the  feeding  is  taken,  the  nipple  should  be 
filled  with  dry  borax  and  held  under  the  faucet,  being  rubbed 
at  the  same  time  between  the  thumb  and  fingers.  It  is  then 
placed  in  a  cup  of  water  containing  one  heaping  teaspoonful 
of  borax.  If  treated  in  this  way  the  nipples  need  not  be 
boiled  out  after  the  first  day,  nor  need  they  be  turned  inside 
out  when  cleaned.  Einse  the  nipple  before  using. 

The  utensils  for  mixing  the  food  must  be  kept  in  a  place 
by  themselves  and  not  used  for  any  other  purpose.  These 
utensils  are  not  many.  A  cheap  measuring  glass,  or  gradu- 
ate, holding  sixteen  ounces  and  divided  into  ounces,  is  a  time- 
saving  device  which  it  is  well  to  have ;  a  wide-necked  pitcher 
that  pours  well  and  holds  two  quarts,  a  glass  funnel  which 
does  not  fit  too  tightly  into  the  neck  of  the  nursing  bottles, 
a  tablespoon  (regulation  size),  a  new  enamel  or  aluminum 
saucepan  for  boiling  the  water  or  food,  and  a  one-quart 
preserving  jar  in  which  to  put  the  gruel  or  boiled  water 
away  until  it  is  cold. 

If  gruel  is  used  to  dilute  the  milk,  it  may  be  made  the 
night  before,  so  that  it  will  be  ice-cold  before  it  is  added  to 
the  milk.  In  some  cases  the  milk  is  boiled  with  the  gruel. 


36  SIMPLIFIED  INFANT  FEEDING 

We  are  now  ready  to  prepare  the  day's  feeding.  The 
bottles,  one  for  each  feeding  throughout  the  day,  are  clean 
and  full  of  borax  water  from  the  day  before.  The  bottle 
rack  is  placed  over  the  sink  and  the  bottles,  one  at  a  time, 
are  placed  in  it,  upside  down,  to  drain.  When  they  are 
empty,  they  are  then  turned  right  side  up  in  the  rack  and 
filled  with  hot  water  in  order  to  rinse  out  the  borax,  and 
are  again  placed  upside  down  to  drain  and  cool  while  the 
food  is  being  mixed. 

The  previously  unopened  bottle  of  fresh  milk  is  then 
poured  into  the  pitcher  so  that  the  cream  will  be  mixed 
evenly  through  it  and  then  poured  back  again  into  the  bottle 
in  which  it  came.  The  proper  amount  of  milk  is  now  measured 
in  the  graduate  and  poured  into  the  pitcher.  Next  the  sugar 
is  measured  with  a  tablespoon  and  added  to  the  water  in  the 
manner  described  in  the  directions  to  mothers  on  page  32.  If 
level  tablespoonfuls  are  ordered,  level  each  with  a  knife. 
A  heaping  tablespoonful  means  all  you  can  get  upon  the 
tablespoon.  Stir  until  the  sugar  is  dissolved  when  the  food 
is  done.  Using  the  funnel,  pour  into  each  bottle  the  amount 
the  baby  is  to  have  at  each  feeding.  Stopper  the  bottles  with 
clean  absorbent  cotton  and  put  the  rack  of  bottles  in  the 
ice  chest  (directly  on  the  ice,  if  possible) .  Wash  the  utensils 
and  put  them  away  for  the  following  day. 

When  the  feeding  time  comes,  place  one  of  these  bottles 
in  a  pan  of  hot  water,  or  in  an  alcohol  bottle  heater.  The 
food  should  be  heated  to  the  body  temperature  when  it  is 
fed.  It  is  as  inadvisable  to  have  the  food  too  hot  as  it  is 
to  have  it  too  cold.  The  temperature  should  be  tested  by 
pouring  a  few  drops  upon  the  forearm  and  never  by  putting 
the  nipple  in  one  *s  mouth,  or  touching  the  finger  to  the  food 
itself.  In  this  way  the  food  is  not  contaminated  by  handling. 

In  winter  it  is  well  to  have  a  woollen  bag  or  knitted  cover 
which  just  fits  the  bottle  and  helps  retain  the  heat  during 
the  twenty  minutes  that  the  baby  is  feeding. 


CHAPTER  HI 

THE   THREE    ESSENTIAL   REQUIREMENTS    FOR 
INFANTS'  FOODS 

Isr  prescribing  food  for  any  infant,  there  are  three  main 
points  for  consideration.  First,  it  should  contain  the  proper 
elements  to  maintain  nutrition  and  to  allow  growth;  second, 
it  should  be  digestible;  and,  third,  it  should  contain  the 
proper  quantity  of  food,  which  is  best  estimated  by  caloric 
standards. 

In  the  past,  many  methods  of  infant  feeding  have  been 
dependent  upon  one  rather  than  upon  all  three  of  these 
equally  important  requirements.  For  instance,  in  the  early 
days  of  the  percentage  feeding,  so  much  emphasis  was  placed 
upon  the  importance  of  having  the  proper  elements  in  the 
food  (that  is,  the  correct  percentage  of  fats,  sugar  and  pro- 
teid,  by  the  use  of  cream  and  top  milks)  that  its  digestibility 
was  neglected.  Simple  mixtures  of  cow's  milk,  water  and 
sugar  usually  fulfil  these  three  requirements  for  an  infant 's 
food,  and  it  is  seldom  necessary  to  use  anything  else. 

PROPER  ELEMENTS  IN  THE  FOOD 

The  elements  of  food  required  by  the  infant  to  maintain 
growth  and  nutrition  are,  as  in  adult  life,  five  in  number: 
proteids,  fats,  carbohydrates,  mineral  salts,  and  water.  The 
form  in  which  they  should  be  fed  to  the  infant  and  the  rela- 
tive quantities  in  which  they  are  demanded  are  different 
from  those  required  in  adult  life. 

The  ideal  bottle  food  would  be  one  that  imitates  breast 
milk  and  would  therefore  contain  3  to  4  per  cent,  of  fat,  6  to  7 
per  cent,  of  sugar  and  1  to  2  per  cent,  of  proteid.  Such  a 
food,  when  made  of  cow's  milk,  is  not  well  borne  except  by 
infants  with  the  strongest  digestive  capacity,  and  it  is,  there- 

37 


38  SIMPLIFIED  INFANT  FEEDING 

fore,  not  practicable  to  attempt  to  feed  these  mixtures  to 
difficult ' '  feeding  cases, ' '  the  kind  of  cases  that  the  physician 
is  usually  called  upon  to  treat.  The  reason  is  obvious.  The 
fat,  sugar  and  proteid  of  cow's  milk  are  of  a  different  kind 
than  those  of  breast  milk.  They  are  intended  for  the  diges- 
tive apparatus  of  the  calf  and  not  for  the  infant's  stomach, 
and,  since  we  must  use  cow's  milk  for  infant  feeding,  we 
should  give  it  in  as  easily  digested  a  form  as  possible. 

Chapin  has  contributed  the  most  convincing  proof  that 
it  is  impossible  to  so  modify  cow's  milk  as  to  duplicate 
mother's  milk.  He  has  studied  this  question  from  a  biologi- 
cal standpoint  and  finds  that  the  milk  of  various  mammals 
curdles  differently,  i.e.,  cow's  and  human  milk  have  practi- 
cally the  same  chemical  composition  with  varying  percent- 
ages, but  physically  they  are  entirely  different.  Cow's 
milk  curdles  in  a  tough,  leathery  mass  because  70  per  cent, 
of  the  digestion  of  the  cow  takes  place  in  the  stomach  and 
nature  provides  a  milk  that  will  conform  with  this  condition. 
Human  milk  curdles  in  a  soft,  flocculent  curd  because  only 
30  per  cent,  of  the  infant's  digestion  takes  place  in  the 
stomach.  In  short,  Chapin  has  shown  that  nature  in  pro- 
ducing the  milk  of  the  various  mammals  provided  it  in  corre- 
spondingly varied  forms,  so  that  each  young  mammal  would 
receive  a  food  that  would  develop  its  particular  digestive 
tract  in  accordance  with  future  needs. 

Fats,  sugar,  and  proteid  are  interchangeable  to  a  limited 
extent.  It  is  not  claimed,  however,  that  the  fats,  sugars,  and 
proteids  are  interchangeable  to  such  an  extent  that  an  infant 
will  thrive  throughout  the  feeding  period  upon  a  food  in 
which  any  one  of  these  elements  is  entirely  lacking. 

The  Proteids. — That  some  proteid  is  an  absolute  necessity 
goes  without  saying,  and  it  has  yet  to  be  proven  that  the  large 
quantities  of  proteid  given  in  whole  milk  mixtures  do  harm 
or,  as  has  been  said  by  some  authorities,  are  an  added  tax  to 


REQUIREMENTS  FOR  INFANTS'  FOODS         39 

the  digestion.  Proteids  are  the  only  kinds  of  food  that  are 
capable  of  replacing  the  continuous,  nitrogenous  waste  of 
the  cells  of  the  body  upon  the  condition  of  which  the  digestion 
and  assimilation  of  the  other  elements  of  the  food  depend. 
The  proteid  is  furnished  by  the  casein  and  albuminoids 
found  in  both  cow 's  milk  and  human  milk. 

Since  cow's  milk  contains  over  3  per  cent,  proteid,  and 
breast  milk  has  only  1  per  cent,  or  2  per  cent.,  this  dement  of 
the  food  can  be  made  to  closely  approach  breast  milk  as  far 
as  the  percentages  are  concerned  by  diluting  the  milk  one- 
third  or  one-half.  One-third  milk  will  give  1  per  cent,  pro- 
tein, one-half  milk  will  give  1^  per  cent,  protein,  whereas 
three-fourths  milk  and  one-fourth  water  will  give  a  mixture 
containing  2*4  per  cent,  protein.  It  must  be  clearly  under- 
stood that  the  kind  of  protein  found  in  cow's  milk  is  very 
different  from  that  found  in  breast  milk.  Both  on  account 
of  the  fat  and  on  account  of  the  protein,  it  is  usually  best 
to  give  no  stronger  dilutions  than  one-half  milk  and  one- 
half  water  to  infants  under  three  or  four  months  of  age  or  to 
infants  who  have  had  much  digestive  disturbance. 

The  Fats. — Theoretically,  the  infant  should  have  4  per 
cent,  of  fat  in  its  food,  because  breast  milk  contains  this 
amount.  But  from  the  practical  stand-point,  this  amount 
of  fat  is  very  difficult  to  digest  and  there  is  no  reason  to 
believe  that  the  infant  cannot  make  use  of  an  extra  amount 
of  protein  and  sugar  (chiefly  the  sugar)  to  take  the  place 
of  some  of  the  fat  which  is  normally  supplied  in  the  breast 
milk.  The  human  economy  is  very  adaptable,  so  much  so 
that  the  Eskimo  lives  almost  entirely  upon  a  protein  and 
fat  diet,  and  certain  other  races  seem  to  thrive  on  high  starch 
diets.  There  can  be  no  reason  why  the  infant  cannot  do  this 
to  a  certain  extent. 

Fats  possess  the  important  property  of  saving  nitrog- 
enous waste,  so  that  when  these  are  properly  supplied  in 
the  food  the  entire  energy  of  the  proteids  may  be  expended 


40  SIMPLIFIED  INFANT  FEEDING 

upon  the  growth  and  nutrition  of  the  cells  of  the  body  with- 
out being  used  up  for  the  production  of  animal  heat.  The 
fats  also  add  to  the  body  weight  by  storing  up  fat.  They 
are  needed  likewise  for  the  growth  of  the  nerve  cells  and 
are  essential  to  the  proper  growth  of  bone. 

Because  the  fat  is  often  so  difficult  to  digest,  it  is  best 
to  use  whole  milk  properly  diluted  or,  in  some  instances  of 
extreme  indigestion,  skimmed  milk.  The  average  cow 's  milk 
containing  4  per  cent,  fat,  when  diluted  three  times  (one  part 
milk  and  two  parts  water),  will  give  a  mixture  of  1.3  per 
cent,  fat,  while  the  same  milk  diluted  two  times  (one  part 
milk  and  one  part  water)  will  give  a  mixture  containing  2  per 
cent.  fat.  In  the  same  way,  three-quarters  milk  and  one- 
quarter  water  will  give  a  mixture  containing  3  per  cent.  fat. 
The  author  believes  and  has  proven  to  his  own  satisfaction 
that  any  deficiency  in  fat  may  be  made  up  by  adding  sugar. 
How  else  can  one  explain  the  splendid  results  obtained  in 
feeding  infants  throughout  the  bottle  period  with  a  mixture 
containing  far  less  fat  than  breast  milk?  For  these  reasons 
it  is  not  necessary  to  use  top-milk  mixtures  or  to  add  cream 
to  milk  mixtures. 

The  Sugar. — The  sugars,  like  the  fats,  cannot  replace  the 
nitrogenous  waste  of  the  body,  but  they  are  important  aids 
to  the  proteids.  Their  chief  use  in  the  human  economy  is 
to  supply  heat  and  energy,  and  they  are  capable  of  replacing 
fat  waste  in  the  body. 

Since  cow's  milk  diluted  three  times  contains  only  1%  per 
cent,  of  sugar  in  the  form  of  lactose,  and  diluted  half  and 
half  contains  only  2  per  cent,  sugar,  it  is  necessary  to  add 
sugar  to  the  bottle  feedings  in  order  to  bring  the  sugar  con- 
tent of  the  food  up  to  that  of  breast  milk. 

The  sugars  most  commonly  used  in  infant  feeding  are 
cane  sugar,  milk  sugar  and  malt  sugar  (maltose  and  dextrin). 

Sugar  is  in  many  ways  the  most  important  element  in 
the  food,  and  in  the  past  two  or  three  years  more  attention 


REQUIREMENTS  FOR  INFANTS'  FOODS        41 

has  been  given  to  it  than  had  been  previously  thought  neces- 
sary, because  clinical  experience  has  brought  out  the  fact 
that  sugars  are,  in  many  instances,  the  primary  cause  of 
indigestion  in  infancy. 

The  Mineral  Salts. — The  mineral  salts  are  of  even  greater 
importance  in  infancy  than  in  later  life,  because  of  the  rapid 
growth  of  the  bony  structure  which  is  going  on  at  this  period. 
The  most  important  salts  are  the  phosphates  of  lime  and 
magnesium  which  are  furnished  in  abundance  in  both  human 
and  cow's  milk.  The  salts  are  also  necessary  for  cell  growth 
and  are  important  constituents  of  the  blood  and  digestive 
juices,  facilitating  secretion,  absorption,  and  excretion. 

The  Water. — The  food  of  all  young  mammals  contains 
from  80  to  90  per  cent,  water,  which  gives  it  the  liquid  form 
adaptable  for  sucking.  Water  is  also  needed  in  large  quanti- 
ties for  the  rapid  elimination  of  the  waste  in  the  body. 


CHAPTER  IV 

DIGESTIBILITY  OF  THE  FOOD 

IT  is  of  the  utmost  importance  to  have  a  food  which  the 
infant  can  digest,  since  it  is  utterly  futile  to  supply  the 
proper  amount  of  food  (fulfil  the  caloric  requirements)  and 
to  supply  the  correct  percentages  of  fat,  carbohydrates  and 
proteid  if  the  food  causes  gastric  or  intestinal  indigestion. 
Simple  milk,  water  and  sugar  mixtures  have  proven  to  be 
more  easily  digested  than  many  of  the  more  complicated 
feedings  which  have  been  used  in  the  past. 

The  Proteids. — We  have  passed  the  period  in  infant  feed- 
ing when  the  proteids  were  considered  a  source  of  all 
indigestion. 

The  proteid  of  cow's  milk  is  composed  of  about  three- 
quarters  casein  (curds)  and  one-quarter  albuminous  proteid 
(whey) .  The  curds  were  formerly  considered  by  many  to  be 
the  element  in  the  food  most  difficult  of  digestion.  For  this 
reason  many  infants  who  had  difficulty  in  digesting  their  food 
were  fed  with  whey  and  cream  mixtures,  the  curds  being  dis- 
carded. This  is  called 1 1  split  protein"  feeding.  As  a  matter 
of  fact,  the  whey,  containing  as  it  does  most  of  the  sugar 
of  the  milk,  is  probably  more  difficult  for  many  infants  to 
digest  than  are  the  curds  themselves  when  properly  treated, 
especially  when  cream  and  artificial  sugar  are  added.  The 
author  has  discarded  the  use  of  the  whey  and  cream  mixtures 
because,  clinically,  it  has  been  found  that  simple  milk  and 
water  mixtures  are  far  more  easily  digested. 

Some  authorities,  in  order  to  overcome  this  imagined 
extreme  indigestibility  of  the  curds,  added  alkalies.  For 
the  most  part,  small  quantities  of  lime  water,  usually  one 
ounce  to  twenty  of  the  food,  were  used  to  overcome  this  diffi- 
culty. So  used,  lime  water  has  little  if  any  effect  upon  the 

42 


DIGESTIBILITY  OF  THE  FOOD  43 

digestibility  of  the  food.  The  main  reason  for  adding  alka- 
lies would  seem  to  be  to  neutralize  the  acid  gastric  juices  of 
the  stomach  in  order  that  the  milk  may  pass  on  into  the 
intestines  as  a  fluid  without  curdling  in  the  stomach.  This 
will  only  be  accomplished  by  adding  large  quantities  of  a 
stronger  alkali  than  lime  water,  and  many  pediatricians  have 
used  sodium  bicarbonate,  sodium  citrate,  or  potassium  car- 
bonate (2  grains  to  every  ounce  of  milk)  for  this  purpose. 
This  probably  has  the  effect  of  preventing  coagulation  in  the 
stomach,  but  it  throws  most  of  the  work  which  the  stomach 
should  do  upon  the  intestines,  and  results  in  intestinal  indi- 
gestion in  many  instances. 

Another  theoretical  reason  for  the  use  of  lime  water  is 
to  supply  the  calcium  deficiency  in  cow's  milk.  It  is  also 
said  to  increase  the  flow  of  hydrochloric  acid  in  the  stomach. 
Clinically  the  author  has  never  felt  that  the  use  of  lime 
water,  in  the  strength  ordinarily  used,  was  of  any  benefit 
whatever,  nor  does  he  believe  that  it  makes  the  slightest 
difference  in  the  digestibility  of  the  food  whether  lime  water 
be  given  or  omitted. 

The  proteid  in  cow's  milk,  when  subjected  to  boiling,  is 
usually  the  most  easily  digested  portion  of  the  milk,  both 
in  the  stomach  and  in  the  intestinal  tract.  Often,  the  sickest 
infants  with  the  weakest  digestion  will  digest  with  ease 
skimmed  milk  in  strong  dilutions  (sometimes  even  undi- 
luted) when  no  artificial  sugar  is  added  to  the  food.  This, 
in  itself,  proves  that  the  proteid  is  not  as  indigestible  as 
it  was  formerly  thought  to  be. 

Gruels  have  also  been  used  to  dilute  cow's  milk  in  order 
to  make  the  proteid  more  digestible.  It  is  true  that  in  the 
test-tube  top  milks  diluted  with  gruels  do  not  coagulate 
with  hydrochloric  acid  and  pepsin  in  as  hard  and  tough 
curds  as  do  milks  diluted  with  plain  water,  but  the  author 
prefers  to  omit  gruels  in  younger,  smaller  infants,  because 
he  believes  that  occasionally  the  gruels  themselves  are  a 


44  SIMPLIFIED  INFANT  FEEDING 

cause  of  gastric  or  intestinal  indigestion.  Infants  over  six 
months  of  age,  who  have  a  normal  digestion,  do  very  well 
upon  gruels  when  used  as  a  diluent  for  the  milk,  but  it  is 
chiefly  for  the  nutritional  value  of  the  flour  (which  gives  an 
additional  amount  of  carbohydrate)  that  gruels  are  given 
at  this  time. 

In  certain  cases  of  diarrhom  in  infants  of  this  age  milk 
boiled  with  the  gruel  has  a  definite  therapeutic  value,  but  on 
the  whole  boiling  the  milk  and  water  together  is  the  most 
satisfactory  way  of  making  the  proteids  digestible. 

Peptonizing  the  milk  has  also  been  popular  in  the  past, 
but  this  method,  too,  usually  fails  to  help  the  digestion  in 
cases  where  help  is  most  needed.  The  author  does  not  be- 
lieve that  it  is  of  any  benefit  to  peptonize  the  food  which  the 
infant  does  not  digest  unpeptonized.  Some  element  of  the 
food  itself  is  at  fault,  and  with  the  proper  knowledge  of 
infant  feeding  one  can  usually  permanently  improve  the 
digestion  by  instituting  the  proper  feeding  and  with  better 
results  than  by  peptonizing  the  food. 

CASE  I 

(A  case  in  which  peptonizing  the  food  did  not  overcome  the  infant's  indigestion 
or  vomiting) 

March  10:  Female,  age  2  months.      Birth  weight,  6  Ib. 

Present  weight,  7  Ib.  2  oz. 
Gain  since  birth,  1  Ib.  2  or. 

General  Condition. — Very  poorly  nourished,  underdeveloped,  good  musculature, 

cries  lustily. 
Stools. — Since  birth,  one  or  two  per  day,  small,  yellow,  normal  consistency  and 

odor,  no  mucus,  curds  or  blood. 
Vomiting. — Since  birth  has  vomited   (most  of  the  feeding)   immediately  after 

feeding  or  within  half  an  hour. 
Appetite. — Hungry. 

Sleep. — Daytime  poor;  at  night  sleeps  twelve  hours  uninterruptedly. 
Temperature,  98.6°  F. 
Chief  Complaint. — Vomiting,  improper  gain  in  weight,  crying. 


DIGESTIBILITY  OF  THE  FOOD  45 

Previous  Food: 

3  oz.  t£p  milk  ( 22  per  cent. 

fat)    3  oz. 

Whole  milk    8  oz.      Fed  3  oz.  every  2  hours,  9  feedings 

Water    16  oz.          in  24  hours. 

Fairchil  d's  Peptogenic 

Powder 3  oz. 

Treatment. — Food  prescribed: 
Whole   milk    ...    10  oz.  ~) 

Water    20  oz.       boiled        F^  4+  °Z"  ™*?  3  h°U™  f  6'  9' 

Sugar     Ooz.  12  A.M.,  3,  6,  9  P.M,  and  2  A.M. 

The  milk  is  to  be  increased  one  ounce  each  day  and  the  water  decreased 
the  same  amount  until  the  formula  is  half  milk  and  half  water,  or 

Milk    ...  15  oz.  ) 

Water     15oz.jboiled 

Six  days  later  the  weight  was  7  Ib.  (a  loss  of  2  oz. ),  the  general  condition 
was  as  above,  the  stools  normal  and  occurring  once  a  day.  The  vomiting  had 
stopped,  the  sleep  was  better  and  the  appetite  still  good. 

The  infant  gained  in  weight  when  sugar  was  added  and  continued  to 
progress  normally.  The  previous  food,  though  peptonized,  had  caused  vomiting 
and  much  discomfort.  The  food  that  was  instituted  was  much  better  digested 
than  the  peptonized  food,  although  it  contained  almost  as  much  milk  as  the 
former.  The  fat  of  the  top  milk  and  the  large  amount  of  milk  sugar  given  in 
the  form  of  peptogenic  milk  powder  caused  indigestion  which  could  not  possibly 
be  overcome  by  peptonizing  the  mixture. 

It  is  now  generally  conceded  that  boiling  the  milk  is  the 
best  and  easiest  and  most  effective  method  of  making  the 
curds  digestible,  and  it  is  therefore  unnecessary  to  add 
alkalies  or  peptonizing  agents  or  gruels  for  this  purpose. 

Boiling  the  milk  has  been  found  of  the  most  help  in  cases 
where  the  proteid  does  not  seem  to  be  well  digested.  Bran- 
naman  has  shown  that  tough,  hard  curds  stay  in  the  stomach 
for  many  hours  when  raw  milk  is  used  and  that  the  curds 
are  flocculent  and  easily  digested  when  the  milk  is  boiled. 
The  author  has  never  seen  a  case  in  which  hard,  bean-like 
curds  occurred  in  the  stools,  where  the  curds  could  not  be 
stopped  by  boiling  the  milk.  This  experience  has  been  re- 


46  SIMPLIFIED  INFANT  FEEDING 

peated  so  many  times  that  there  cannot  be  the  slightest  doubt 
of  the  beneficial  influence  of  boiling  the  milk  where  the  neces- 
sity for  such  boiling  is  indicated  by  the  condition  of  the 
stools.  (See  Chapter  XXII.) 

CASE  II 

(A  case  in  which  intestinal  indigestion — diarrhoea — was  overcome  by  boiling 
the  milk) 

May   6:   Male,    age   3    months.       Birth  weight,  6  Ib.  8  oz. 

Present  weight,  8  Ib.  4  oz. 
Gain  since  birth,  1  Ib.  12  oz. 

General  Condition. — Fairly  well  nourished. 

Stools. — For  four  days  has  had  each  day  6  or  7  loose,  watery  stools,  yellow  or 

green,  of  normal  odor,  with  considerable  mucus  and  many  tough,  hard 

curds,  but  no  blood. 
Vomiting. — None. 

Appetite. — Poor.     (Leaves  some  of  the  food.) 
Sleep. — Restless  and  intermittent. 
Temperature. — 98.6°  F. 
Chief  Complaint. — Diarrhoea. 

Previous  Food: 

Milk    .  .    18  oz.  1 

_,  ,  i       ,    ..   ,       Fed    every    3    hours,    7    feedings    in 

Water 18  oz.  L  unboiled 

24  hours. 
Cane  sugar  ...      1  oz.  j 

Treatment. — Food  prescribed : 

Milk    18  oz.  1       .  Divide   into   7    feedings   of   5   oz. 

Water 18  oz.  j  boiled  each,  to  be  given  at  6,  9,    12 

Sugar   1  oz.  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

May  9 :  3  days  later.      Weight,  8  Ib.  4  oz. 

Xo  gain  or  loss. 
General  Condition. — Unchanged. 
Stools. — Two  large,  'firm,  homogeneous,  yellow  stools  of  normal  odor,  containing 

no  curds,  mucus  or  blood. 

The  curds  did  not  reappear  in  the  stools  later  when  the  milk  and  sugar  was 
gradually  increased  in  quantity.  It  is  usually  advisable  to  stop  all  sugar  tem- 
porarily in  such  cases,  but  this  case  is  cited  to  show  that  without  changing 
the  food  in  any  other  way,  except  by  boiling  the  milk,  diarrhoea  can  be  occasion- 
ally overcome.  (See  diarrhoea.) 

In  a  way,  it  is  a  mistake  to  speak  of  protein  indigestion 
or  fat  indigestion  or  sugar  indigestion  as  separate  entities, 
for  in  this  way  a  false  impression  is  gained.  Undoubtedly 


DIGESTIBILITY  OF  THE  FOOD  47 

an  excess  of  any  one  of  these  constituents  of  the  food  will 
cause  digestive  disturbances,  but  once  the  digestion  is  upset 
by  the  fat  or  sugar  or  protein,  the  power  to  digest  any  of  the 
elements  of  the  food  is  diminished.  An  infant  whose  diges- 
tion has  been  badly  upset  by  too  much  fat  cannot  digest  the 
usual  and  normal  amount  of  either  sugar  or  proteid.  It  is 
just  as  ridiculous  to  speak  of  such  a  case  as  "fat  indiges- 
tion" as  it  would  be  to  speak  of  "green  apple  indigestion" 
in  an  older  child  who  has  eaten  green  apples  and  has,  there- 
fore, temporarily  lost  its  power  of  digesting  any  kind  of 
food.  In  other  words,  a  baby  who  has  been  fed  a  high  fat 
mixture  until  it  has  caused  indigestion,  might  have  casein 
curds  in  the  stools  because  the  digestive  apparatus  is  not 
in  a  condition  to  take  care  of  the  proteid.  The  same  is  true 
of  l '  sugar  indigestion. ' '  Usually  it  is  not  sufficient  to  sim- 
ply cut  down  the  fats  in  treating  an  infant  with  indigestion 
caused  by  fat,  nor  is  it  effective  simply  to  cut  down  the 
sugar  when  that  is  the  source  of  the  disturbance.  The  indi- 
gestion itself  must  be  treated  as  such.  For  this  reason,  in 
addition  to  cutting  down  the  fats  and  sugar,  all  infants  with 
indigestion  should  be  given  boiled  milk  in  order  to  increase 
the  digestibility  of  the  protein.  (See  page  275.) 

The  Fats. — It  is  now  generally  conceded  that  high  fat 
mixtures  are  not  to  be  used  with  infants  having  digestive 
disturbances,  and  the  majority  of  pediatricians  at  the  pres- 
ent time  believe  that,  even  for  well  infants,  the  fat  as  it 
occurs  in  the  average  (4  per  cent.)  cow's  milk  is  sufficient 
to  maintain  the  proper  nutrition  when  diluted  correctly  for 
the  individual  infant.  In  this  country,  where  percentage 
feeding  has  been  popular  and  carried  to  extremes,  the  fat 
has  probably  been  the  cause  of  more  indigestion  than  any 
other  element  of  the  food.  At  the  present  time,  with  a  few 
notable  exceptions,  those  who  are  still  percentage  enthusi- 
asts do  not  use  milk  that  contains  more  than  8  per  cent,  faf 
(this  diluted  with  equal  parts  of  water  gives  a  mixture  con- 


48  SIMPLIFIED  INFANT  FEEDING 

taining  4  per  cent,  fat;  diluted  three  times  gives  2%  per 
cent,  fat,  etc.),  and  simple  mixtures  of  whole  milk  are  be- 
coming more  and  more  popular.  For  this  reason,  indiges- 
tion caused  by  high  fats  is  not  seen  as  often  as  when  12 
per  cent,  or  even  20  per  cent,  milk  was  used  to  make  the 
dilutions.  There  is  very  little  danger  of  the  fats  causing 
indigestion  in  well  infants  when  proper  dilutions  of  whole 
milk  (4  per  cent,  fat)  are  used.  Most  infants  who  already 
have  indigestion  from  fat  may  be  started  with  one-third 
milk  and  two-thirds  water,  provided  the  sugar  is  left  out 
temporarily,  although  it  is  occasionally  necessary  to  use 
skimmed  milk  in  severe  cases  of  indigestion  caused  by  fat. 

CASE  III 

(A  case  of  intestinal  indigestion — diarrhoea — caused  by  too  much  fat,  over- 
come by  cutting  down  the  fat,  omitting  the  sugar,  and  boiling  the  milk) 
August  6 :  Female,  age  6  weeks.      Birth  weight,  7  Ib.  8  oz. 

Present  weight,  8  Ib. 
Gain    since  birth,    8   oz. 

General  Condition. — Poorly  nourished,  feeble  cry. 

Stools. — For  four  days,  each  day  6  or  7  small,  green  or  yellow  watery  stools  of 

normal  odor,  with  much  mucus  and  many  soft  and  tough  curds,  no  blood. 

Formerly  constipated. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Poor,  night  and  day. 
Temperature,  98.6°  F. 
Chief  Complaint. — Diarrhoea,  fretfulness  and  sleeplessness. 

Previous  Food: 
Milk,  top  2  oz.  from 

each  of  3  qt.  bottles 

Fed  3  oz.  every  2l/2  hours,  8  feedings  in 
(24  per  cent,  fat)  .      6  oz. 

24  hours. 
Water  14  oz. 

Sugar  of  milk 6  teaspoonfuls 

Treatment. — Food  prescribed : 

Whole  milk  ....    10  oz.  |      .  Divide  into  7  feedings  of  4+  oz, 

Water 20  oz.  j"  b  each.    Feed  every  3  hrs.  at  6,  9, 

Sugar 0  12  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 


49 

August  10:     4  days  later. 
General  Condition. — The  same. 
tftools. — One  large,  yellow,  firm,  homogeneous  stool,  of  normal  odor,  with  no 

mucus,  curds  or  blood. 
Vomiting. — None. 
Appetite. — Ravenous. 
tileep. — Poor  (on  account  of  hunger). 

The  high  percentage  of  fat  that  was  used  in  the  first  formula  caused  diar- 
rhoea and  at  the  same  time  did  not  furnish  enough  nourishment  for  the  infant. 
In  some  instances,  vomiting  also  is  caused  by  these  high  fat  mixtures.  Subse- 
quently the  food  was  gradually  increased  in  strength  and  sugar  was  added  with 
no  return  of  the  diarrhoea  or  intestinal  indigestion. 

The  Sugar. — Sugar  is,  in  many  ways,  the  most  important 
element  in  the  food.  At  least,  it  gives  the  most  trouble  when 
wrongly  used,  and,  by  manipulating  the  artificial  sugar 
properly,  digestive  disturbances  can  often  be  overcome  with- 
out changing  the  food  in  any  other  way.  Sugar  serves  two 
purposes  in  an  infant's  food.  First,  it  supplies  a  large 
amount  of  nourishment  because  of  its  high  caloric  value, 
and,  second,  it  helps  to  make  up  any  deficiency  in  the  fat 
which  may  possibly  exist  in  the  food.  Besides  this,  it  is 
often  a  laxative.  Fresh  cow 's  milk  is  not  a  properly  balanced 
diet  and  an  infant  cannot  be  made  to  gain  and  thrive  upon 
milk  and  water  mixtures  without  the  addition  of  sugar  or 
some  other  carbohydrate. 

It  is  still  a  question  what  kind  of  sugar  may  preferably 
be  used  in  infant  feeding.  Many  theoretical  papers  have 
been  written  upon  the  subject,  all  of  which  seem  logical, 
each  one  proving  its  case  for  a  different  kind  of  sugar.  It 
is  hard,  too,  to  prove  clinically  that  one  form  of  sugar  is 
better  than  another  because  of  other  considerations  entering 
into  the  discussion  besides  the  sugar,  different  authorities 
using  various  kinds  of  formulas.  Some  authorities  claim 
that  malt  sugar  is  more  laxative  than  cane  sugar  (ordinary 
granulated  sugar) ,  while  others  state  that  the  reverse  is  true. 

The  author  can  give  only  his  own  opinion,  based  upon 
actual  clinical  experience  rather  than  upon  theoretical 

4 


50  SIMPLIFIED  INFANT  FEEDING 

grounds.  He  has  found  that  the  ordinary  infant,  having  a 
normal  digestive  capacity  and  never  having  had  much  diges- 
tive disturbance,  will  do  very  well  upon  cane  sugar.  Malt 
sugar  (maltose  and  dextrin),  however,  seems  to  be  more 
easily  digested  and  better  taken  care  of  by  infants  having 
had  much  digestive  trouble.  There  are  many  malt  sugars  on 
the  market,  most  of  which  are  composed  of  about  one-half 
dextrin  and  one-half  maltose.  One  that  is  largely  used  in 
this  country  is  dextri-maltose,1  which  is  similar  to  the  Ger- 
man * '  Nahrsucker,  ' '  a  preparation  that  is  very  expensive  on 
account  of  its  being  imported.  Milk  sugar  has  been  the  sugar 
of  choice  for  so  many  years  that  it  would  seem  almost  heresy 
to  speak  against  it.  However,  malt  sugar  and  cane  sugar  are 
now  fast  taking  its  place,  and  the  author  believes  that  the 
two  latter  are  of  greater  value.  He  now  uses  milk  sugar 
very  little,  believing  that  it  is  often  a  source  of  indigestion 
in  normal  infants,  and  that  it  is  not  as  well  borne  by  those 
having  digestive  disturbances. 

Finkelstein  and  Meyer  believe  that  milk  sugar  is  the 
primary  cause  of  fermentative  dyspepsias  of  infancy,  and 
that  when  there  is  a  disturbance  of  the  utilization  of  fat  in 
these  conditions  it  is  a  secondary  manifestation. 

Occasionally  it  is  necessary  to  change  from  one  kind  of 
a  sugar  to  another  because  an  intolerance  for  one  sugar  has 
been  acquired.  For  instance,  an  infant  who  has  been  get- 
ting malt  sugar  has  an  attack  of  diarrhosa  (intestinal  indi- 
gestion) or  perhaps  there  have  been  several  attacks.  All 
sugar  is  omitted  from  the  food  and  the  stools  become  normal 
again.  A  small  amount  of  malt  sugar  is  then  added  to  the 
food  and  soon  the  stools  become  loose  again.  This  indicates 
that  this  infant  has  a  more  or  less  permanent  intolerance 
for  malt  sugar,  or  that  the  malt  sugar  has  been  increased 
too  rapidly.  This  infant  should  never  be  given  malt  sugar 
again  but  instead  cane  sugar  should  be  used.  Some  infants 

1  Dextri-Maltose  is  made  by  the  Mead  Johnson  Co.,  Jersey  City,  N.  J. 


DIGESTIBILITY  OF  THE  FOOD  51 

acquire  an  intolerance  for  all  kinds  of  sugar  so  that  when- 
ever a  small  amount  of  sugar  of  any  kind  is  added  to  the 
milk  and  water  mixture,  the  stools  get  loose  and  an  attack 
of  intestinal  indigestion  results.  Since  it  is  impossible  to 
make  a  small  infant  increase  its  weight  and  prosper  when 
it  is  fed  milk  and  water  alone,  it  is  then  necessary  to  use 
a  food  which  will  accomplish  this  end  without  the  addition 
of  artificial  sugar.  Dry  milk  answers  this  purpose  remark- 
ably well  because  a  rapid  increase  in  weight  can  be  brought 
about  by  the  use  of  dry  milk  and  water  alone  without  the 
addition  of  artificial  sugar.  (See  chapter  on  Dry  Milk, 
page  291.) 

There  is  a  certain  class  of  cases  that  do  not  do  well  on 
either  dextri-maltose,  cane  sugar  or  milk  sugar,  and  who 
thrive  astonishingly  well  upon  malt  soup  extract  made  after 
Keller's  formula  (see  page  302,  malt  soup).  Malt 'soup 
extract  is  a  viscous  liquid  of  amber  color  about  the  con- 
sistency of  very  thick  syrup.  It  contains  62  per  cent,  maltose, 
and  seven  grains  of  potassium  carbonate  are  added  to  every 
ounce  of  the  malt  extract.  It  is  used  with  the  proper  milk 
and  water  mixtures,  adding  equal  parts  (by  bulk)  of  wheat 
flour.  Generally,  however,  most  babies  thrive  satisfac- 
torily on  the  less  expensive  and  more  easily  prepared 
forms  of  sugar. 

CASE  IV 
(Illustrating  the  use  of  malt  soup  extract  when  other  kinds  of  sugar  have 

caused  digestive  disturbances) 
December  14:     Female,  age  5  months.      Birth  weight,  8  Ib.  14  oz. 

Present  weight,  13  Ib.  13  oz. 
Gain  since  birth,  4  Ib.  15  oz. 
General  Condition. — Pale,  moderately  well  nourished,  extremely  rhachitic,  with 

markedly  asymmetrical  head.     Eczema  for  last  five  or  six  weeks. 
Stools. — One  or  two  hard  constipated  stools  a  day,  green  in  color,  occasionally 

with  some  mucus. 
Vomiting. — Very  little. 
Appetite. — Exceedingly  hungry. 
Sleep. — Poor;  cries  with  colic  night  and  day. 
Temperattire,  98.6°  F. 


52  SIMPLIFIED  INFANT  FEEDING 

Chief  Complaints. — Colic,  hunger,  eczema,  hard  constipated  stools,  rickets. 
Previous  Food. — Breast-fed  for  the  first  two  months,  developing  rickets  during 

that  time.    Since  then  has  been  carefully  fed  with  the  proper  milk  mixtures. 

Both  cane  sugar  and  dextri-maltose  had  been  used.    Throughout  this  period 

there  was  indigestion  most  of  the  time  even  when  the  stools  were  normal. 

The  baby  has  not  gained  in  weight  for  the  last  month.     For  the  last  week 

has  been  fed 

Milk    21  oz.  \  Divided  into  6  feedings,  fed  6  oz. 

Water 21  oz.  v  boiled  every  3  hours  at  6,  9,  12  A.M., 

Dextri-maltose.  .    %  oz.  )  3,  6,  9  P.M. 

Treatment. — Food  prescribed: 

Milk    21  oz. 

Water 21  oz.  Divide  into  6  bottles;  feed  6  oz.  every 

Malt  soup 1  tablespoonful  3  hours  at  6,  9,  12  A.M.,  3,  6,  9  P.M. 

Wheat  flour 1  tablespoonful 

December  21:     7  days  later.      Weight,  14  Ib.  5  oz. 

Gain,  8  oz. 

General  Condition. — As  at  last  date,  except  that  infant  looked  much  happier, 
as  shown  by  the  facial  expression.  Eczema  is  somewhat  better. 

Stools. — One  soft,  smooth,  brown,  normal  stool  a  day. 

Vomiting. — None. 

Appetite. — Very  hungry. 

•SVeep. — Much  improved;  never  cries  except  immediately  before  feeding  when 
hungry. 

Treatment. — Food  prescribed : 

Divide    into   6    bottles;    feed   6+    oz. 

every  3  hours  at  6,  9,  12  A.M.,  3,  6, 
Malt  soup 2  tablespoonfuls          « 

Wheat  flour 2  tablespoonfuls 

December  28:     7  days  later.      Weight,  15  Ib. 

Gain,  1 1  oz. 

General  Condition. — Improved ;  eczema  almost  entirely  disappeared. 
Stools. — One  normal  stool  a  day. 
To  mi  t  ing. — None. 
Appetite. — Good. 
Sleep. — Good. 

This  infant  continued  to  do  well  and  to  gain  about  eight  ounces  a  week 
on  the  above  mixture.  The  immediate  improvement  when  malt  soup  was 
started  was  remarkable,  as  is  often  the  case.  Although  there  had  previously 
been  no  gain  in  weight  during  the  last  month  xinder  the  most  careful  super- 
vision and  regulation  of  the  food,  the  very  first  week  on  this  formula  produced 
a  gain  of  eight  ounces,  the  baby  stopped  crying,  and  all  signs  of  colic  and 
indigestion  disappeared. 


DIGESTIBILITY  OF  THE  FOOD  53 

It  is  well  to  bear  constantly  in  mind  the  laxative  action 
of  sugar,  for  infants  who  have  a  tendency  to  diarrhea  can 
take  less  sugar  in  the  food  than  can  those  who  have  a 
tendency  to  constipation.  Older  infants  who  have  a  tend- 
ency to  diarrhoea  and  who  get  up  intestinal  indigestion  if 
sugar  is  added  to  the  food  may  have  the  sugar  deficiency 
made  up  in  gruels,  cereals  and  breadstuffs.  These  infants 
may  digest  their  food  perfectly  as  long  as  there  is  no  arti- 
ficial sugar  in  the  food,  but  as  soon  as  the  sugar  is  added 
an  attack  of  diarrhoea  follows. 

CASE  V 

(A  case  of  sugar  idiosyncrasy  in  which  any  sugar  whatever  gave   rise  to 
diarrhoea ) 

July   19 :     Female,  age  9  months.      Birth  weight,  5  Ib.  3  oz. 

Present  weight,  15  Ib.  8  oz. 

.,       ,.  Gain  since  birth,  10  Ib.  5  oz. 

General  Condition. — Excellent. 

Stools. — Many  attacks  of  diarrhoea  since  birth.     Ten  days  ago  began  again 

having  5  or  6  stools  per  day,  brown,  watery,  foamy,  sour  smelling,  with 

some  mucus  but  no  curds  or  blood. 
Vomiting. — None. 

Appetite. — Poor;  leaves  2  or  3  oz.  at  a  feeding. 
Temperature,  98.6°  F. 
/S'ieep. — Good. 

Chief  Complaint. — Recurrent  diarrhoea. 
Previous  Food  : 

Milk     32  oz.  Fed  8  oz.  every  3  hours,  6  feedings 

Water 16  oz.  in  24  hours. 

Sugar   y2  to  1%  oz.       (The  various  kinds  of  sugar  had 

Treafment.-Food  prescribed:  been  used  at  different  times') 

Water 24  oz.  )  ...    ,       Divide  into  6  bottles  of  8  oz.  each. 

Milk 24  oz.  f  b  Feed  every  3  hours  at  6,  9,  12 

Sugar 0  A.M.,  3,  6,  9  P.M. 

In  four  days  the  stools  had  become  normal  (2  per  day)  and  remained  so  as 
long  as  no  sugar  was  added  to  the  food.  However,  it  was  subsequently 
attempted  to  add  the  various  kinds  of  sugar,  including  cane  sugar,  dextri- 
maltose  and  malt  soup,  resulting  in  diarrhoea  each  time  because  of  this  infant's 
peculiar  susceptibility  to  any  form  of  sugar.  Since  she  was  nine  months  of  age 
it  was  found  best  to  make  up  the  deficiency  in  carbohydrates  with  gruels, 
cereals,  etc.,  and  the  baby  eventually  progressed  nicely  with  a  food  free  of 
artificial  sugar.  It  is  not  possible  to  make  up  this  carbohydrate  deficiency 
entirely  with  starch,  in  younger  infants  for  whom  the  dry  milk  is  preferable. 


54  SIMPLIFIED  INFANT  FEEDING 

The  Quantity  of  Sugar. — A  fixed  quantity  of  sugar,  either 
one  ounce  or  one  and  a  half  ounces  (by  weight) ,  may  be  used 
in  feeding  all  well  babies,  provided  they  have  the  power  to 
digest  this  amount,  because  it  has  been  found  from  a  prac- 
tical standpoint  that  such  an  amount  supplies  the  carbohy- 
drate needs,  supplementing  the  sugar  that  the  cow's  milk 
itself  contains.  Even  though  the  quantity  of  artificial  sugar 
remains  constant,  the  total  amount  of  sugar  in  the  food 
increases  with  the  increase  in  the  quantity  of  milk.  Whether 
one  or  one  and  a  half  ounces  is  used  depends  upon  the 
infant's  weight.  A  well  infant  under  ten  pounds  in  weight 
should  receive  one  ounce  of  sugar  in  twenty-four  hours  and 
an  infant  over  ten  pounds  may  have  one  and  a  half  ounces 
of  sugar  in  twenty-four  hours.  It  is  well,  however,  not  to 
give  this  amount  of  sugar  at  first.  (Two  level  tablespoon- 
fuls  of  cane  sugar — levelled  with  a  knife — or  three  of  milk 
sugar  or  four  of  dextri-maltose,  equal  one  ounce  by  weight.) 

The  rapidity  with  which  the  sugar  is  increased  to  one  or 
one  and  a  half  ounces  depends  upon  (1)  whether  the  infant 
has  formerly  had  sugar  or  not,  or  (2)  whether  there  has 
been  previously  any  diarrhoea  or  vomiting,  and  (3)  upon 
the  severity  and  duration  of  the  attacks. 

(1)  The  infant  who  has  been  fed  a  sugar-free  food,  or  one 
without  any  artificial  sugar  in  it,  must  have  his  tolerance 
for  sugar  gradually  increased  by  increasing  the  sugar  slowly. 
If  one  ounce  of  sugar  in  the  twenty-four-hour  amount  is 
given  at  first,  diarrhoea  or  vomiting  may  be  the  result. 
For  this  reason,  the  sugar  must  be  added  one  teaspoonful 
at  a  time  and  at  intervals  of  two  or  three  days,  until  the 
required  amount  is  reached.  This  does  not  seem  to  be 
generally  understood,  particularly  by  those  who  use  stated 
formulas.  If  a  sugar  intolerance  is  once  brought  on  by  too 
much  sugar,  an  infant  may  never  have  as  great  a  tolerance 
for  sugar  again.  It  is  a  great  temptation  to  increase  the 
sugar  rapidly  when  an  infant  is  hungry  and  crying  and 
really  needs  more  food,  but  yielding  to  this  temptation  is 


55 

almost  sure  to  end  in  trouble.  When  the  quantity  gets  as 
high  as  four  teaspoonfuls  the  sugar  is  then  measured  with 
a  tablespoon  levelled  with  a  knife,  because  tablespoons  run 
much  more  uniform  in  size. 

CASE  VI 

(A  case  in  which  the  sudden  addition  of  a  large  amount  of  sugar  caused  intes- 
tinal indigestion   (diarrhoea),  showing  the  importance  of  increasing  the 

sugar  gradually) 
December  3.     Male,  age  7  months       Birth  weight,  5  Ib. 

Present  weight,  12  Ib.  4  oz. 
Gain  since  birth,  7  Ib.  4  oz. 
General  Condition. — Pale,  fairly  well  nourished,  musculature  fair,  rhachitic 

rosary,  flaring  of  ribs,  Harrison's  groove,  no  teeth. 
Stools. — Habitually  constipated;  one  hard  stool  a  day  with  the  aid  of  milk  of 

magnesia. 

Vomiting. — Occasional. 
Appetite. — Good. 
Temperature,  98.6°  F. 
Sleep. — Good,  night  and  day. 
Chief  Complaint. — Constipation. 
Previous  Food  : 

Milk   (unboiled)    1  cup      Fed  8  oz.  every  3  hours,  7  feedings 

Water    1  cup          in  24  hours. 

Sugar     .  .1 0  (This  formula  was  made  up  sev- 

eral times  a  day) 

The  mother  had  been  advised  by  a  neighbor  to  put  sugar  in  the  food  on 
account  of  constipation,  which  was  a  good  suggestion  had  it  been  properly  done. 
Instead  of  adding*  it  gradually,  she  gave  one  and  a  half  ounces  of  cane  sugar 
the  first  day,  with  the  result  that  within  a  short  time  the  stools  became  loose, 
and  the  slight  vomiting  already  present  was  increased.  This  baby  did  not  have 
permanent  intolerance  of  sugar  because,  after  the  diarrhoea  was  stopped,  sugar 
was  gradually  added  (%  oz.  every  two  or  three  days  up  to  1%  oz.  in  24  hours) 
without  any  ill  effects. 

(2)  If  cane  sugar  or  milk  sugar  has  been  used  in  an 
infant's  food  and  it  is  considered  desirable  to  change  to 
malt  sugar,  one  must  be  almost  as  cautious  in  increasing 
the  sugar  as  though  the  infant  had  never  had  any  sugar  at 
all.  The  same  is  true  of  changing  from  milk  sugar  or  malt 
sugar  to  cane  sugar.  When  a  new  kind  of  sugar  is  used  the 
tolerance  for  that  sugar  must  be  increased  by  gradually  in- 
creasing the  amount  of  sugar  just  as  carefully  as  though  the 
infant  had  previously  never  taken  any  sugar  at  all. 


56  SIMPLIFIED  INFANT  FEEDING 

CASE  VII 

(A  case  of  indigestion  caused  by  a  top  milk  and  an  excessive  amount  of  milk 
sugar,  showing  the  necessity  of  gradually  increasing  the  quantity  of  sugar 
when  the  kind  of  sugar  is  changed) 

October  31:     Male,  age  9  months.       Birth  weight,  7  Ib. 

Present  weight,  14  Ib.  10  oz. 
Gain  since  birth,  7  Ib.  10  oz. 

General  Condition. — Fairly  well  nourished,  underdeveloped,  pale. 
Stools. — Two  normal  a  day. 
Vomiting. — None. 
Appetite. — Good. 
Temperature,  98.6°  F. 
Sleep. — Good. 

Chief  Complaint. — Not  gaining  properly  in  weight;  has  occasional  attacks  of 
colic,  poor  appetite,  coated  tongue  and  foul  breath. 

Previous  Food: 

Milk,  top  16  oz.  (7  per  cent,  fat)  ..  16  oz.      Fed  5   oz.   every    3  hours, 

Barley  gruel  16  oz.         6  feedings  in  24  hours. 

Milk  sugar   2  oz. 

Treatment. — Food  prescribed : 

Whole  milk  ....   20  oz.  )  Divide  into  6   feedings  of   8  oz. 

Water 28  oz.  v  boiled  each.    Feed  every  3  hours  at  6, 

Cane  sugar %  oz-  J  9,  12  A.M.,  3,  6,  9  P.M. 

Each  day  increase  the  milk  one  ounce  and  decrease  the  water  one  ounce 
up  to 

Milk  24  oz.  } 

Water    24  oz.  }  *°iled 

Cane  sugar  *4  oz. 

Every  third  day  increase  the  sugar  %  oz.  up  to  1  y2  oz.  in  24  hours. 
With   this   gradual   increase   there   was   no   recurrence   of   the   digestive 
disturbances  and  a  progressive  gain  in  weight  took  place  as  soon  as  the  caloric 
requirements  were  fulfilled. 

(3)  Infants  who  have  had  many  attacks  or  one  prolonged 
attack  of  vomiting  or  diarrhoea  may  not  be  able  to  take  any 
sugar  at  all  for  a  time.  If  an  infant  has  recently  recovered 
from  a  diarrhoea  of  not  more  than  one  or  two  weeks '  stand- 
ing, or  if  it  has  never  had  more  than  one  or  two  attacks  of 
diarrhoea,  the  sugar,  either  malt  sugar  or  cane  sugar,  will 
be  well  borne  if  it  is  increased  very  gradually.  It  should 
be  added  one  teaspoonful  at  a  time  in  such  instances.  One 
rarely  regrets  increasing  the  sugar  too  slowly  in  infants  that 
have  had  diarrhoea. 


CHAPTER  V 

THE  PROPER  QUANTITY  OF  FOOD  TO  SUPPLY 
THE  CALORIC  NEEDS 

IT  is  a  well-known  principle  of  physiology  that  every 
individual  needs  a  certain  definite  quantity  of  food  to  main- 
tain nutrition  and  to  supply  heat  for  the  body,  to  make  up 
for  the  loss  of  heat  from  the  body  surface,  and  to  furnish 
energy  used  in  muscular  and  organic  activity.  The  amount 
of  food  needed  varies  with  the  size  of  the  individual,  with 
the  condition  of  his  nutrition,  with  the  amount  of  energy 
which  he  expends,  and  with  the  heat  he  loses.  The  infant 
normally  doubles  his  weight  in  the  first  six  months  of  life 
and  therefore  needs  an  extra  supply  of  food  for  this  purpose. 
The  definite  quantity  of  food  every  individual  must  receive 
is  best  expressed  in  terms  of  calories. 

There  is  nothing  mysterious  about  calories.  A  ton  of 
coal  put  into  a  furnace  has  a  given  value,  measured  by  the 
amount  of  heat  and  possibly  the  energy  it  supplies  to  an 
engine.  The  term  or  unit  which  is  used  to  express  the  value 
of  this  coal  is  a  calorie.1  A  ton  of  coal,  therefore,  has  a 
certain  definite  caloric  value.  In  the  same  way,  an  ounce 
of  milk  when  utilized  by  the  human  economy  has  a  certain 
definite  value,  and  will  produce  a  certain  amount  of  heat, 
energy  and  growth.  An  ounce  of  sugar  or  flour  or  any 
other  food  also  has  a  certain  definite  caloric  value.  The 
values  of  these  different  foods  have  been  determined  by 
physiologists  and  chemists  and  the  caloric  values  of  all 
foods  are  now  definitely  fixed  and  known.  It  is  a  more 
or  less  complicated  matter  to  reckon  the  number  of  calories 
that  an  adult  takes  in  twenty-four  hours,  because  the  food 

1  A  calorie  is  the  amount  of  heat  necessary  to  raise  the  temperature  of 
1  kilogramme  of  water  1°  C. 

57 


58  SIMPLIFIED  INFANT  FEEDING 

is  so  varied  and  the  amounts  are  often  difficult  to  measure, 
but  it  is  a  very  simple  process  to  reckon  calories  for  infants 
when  their  food  is  limited  to  milk,  sugar,  and  possibly  one 
of  the  cereal  flours.  We  practically  have  only  four  figures 
to  remember  in  the 

CALORIC  VALUE  OF  INFANTS'  FOODS 

1  oz.  of  milk  *  =20  calories. 

1  oz.  of  sugar  =120  calories  (any  kind  of  sugar). 

(by  weight) 

1  oz.  of  flour  =100  calories. 

(by  weight) 

1  oz.  malt  soup  extract  =    90  calories. 

(by  weight) 

2  scant  tablespoonfuls  of  malt  soup    extract  =  1  oz.  by  weight. 

2  level  tablespoonfuls  of  cane  sugar  =  1  oz.  by  weight. 

3  level  tablespoonfuls  of  milk  sugar  =  1  oz.  by  weight. 

4  level  tablespoonfuls  of  dextri-maltose  =  1  oz.  by  weight. 
4  level  tablespoonfula  of  flour  =  1  oz.  by  weight. 

(Tablespoons  to  be  levelled  with  a  knife) 

The  only  other  figures  that  we  have  to  remember  are  the 
number  of  calories  per  pound  weight  the  individual  infant 
needs,  since  all  infants  do  not  require  the  same  number  of 
calories. 

CALORIC  REQUIREMENTS  OF  BOTTLE-FED  INFANTS 

Fat  infants  over  four  months  of 
age need  40  to  45  cals.  per  Ib. 

Average  infants  under  four 
months  of  age  and  moder- 
ately thin  infants  of  any  age .  need  50  to  55  cals.  per  Ib. 

Emaciated  infants  (varying 
with  the  degree  of  emacia- 
tion)    need  60  to  65  cals.  per  Ib. 

The  very  fat  infant  has  less  body  surface  in  proportion 
to  its  weight  and  therefore  loses  less  heat  from  the  surface 

8  See  table  of  caloric  values  of  milk,  page  379. 


FIG.  5. — (a)  Emaciated  infant;  (b)  poorly  nourished  infant;  (c)  moderately  well-nourished 
infant;  (rl)  well-nourished  infant. 


FOOD  TO  SUPPLY  THE  CALORIC  NEEDS        59 

of  the  body  than  the  emaciated  infant.  A  fat  man  feels 
warmer  in  the  hot  weatner  than  a  thin  man,  since  the  fat  man 
has  not  as  much  body  surface  in  proportion  to  his  weight 
as  the  thin  man.  It  can  readily  be  seen  that  a  man  weighing 
200  pounds  cannot  have  anywhere  near  twice  as  much  body 
surface  as  a  man  weighing  100  pounds,  and,  therefore,  since 
a  large  amount  of  food  that  we  take  is  lost  in  heat,  the  fat 
man  does  not  need  as  much  food  in  proportion  to  his  weight 
to  maintain  his  nutrition  and  to  utilize  in  heat  and  energy. 
For  the  same  reason  the  fat  infant  does  not  need  as  many 
calories  as  the  thin  one.  The  number  of  calories  which  in- 
fants need  has  been  determined  by  metabolism  and  calori- 
metric  experiments ;  also  by  taking  a  large  series  of  infants 
of  various  ages,  weights,  and  nutritional  conditions,  and 
ascertaining  by  clinical  observation  the  number  of  calories 
.  they  require  to  develop  properly  and  gain  in  weight. 

When  we  see  an  infant  for  the  first  time,  it  is  a  matter 
of  judgment  whether  it  is  a  40-calorie  infant  or  a  60-calorie 
infant,  but  with  the  above  standards  to  help  us  out  it  is 
fairly  easy  to  determine  this  matter,  especially  after  a  little 
experience.  For  instance,  if  we  see  an  extremely  emaciated 
infant,  we  can  tell  at  a  glance  that  it  must  take  and  digest 
65  calories  per  pound  in  order  to  maintain  nutrition  and 
make  the  proper  gain  in  weight.  On  the  other  hand,  if  it  is 
very  fat  and  over  Jour  or  five  months  of  age,  we  know  that  it 
will  probably  do  well  on  40  or  45  calories  per  pound,  and  if 
in  our  opinion  it  seems  to  be  the  average  infant,  50  or  55 
calories  per  pound  will  be  sufficient  food  for  it. 

As  an  example,  take  an  infant  that  weighs  twelve  pounds 
at  four  months  of  age.  It  would  be  about  the  average  infant 
and  if,  after  examining  it,  it  was  seen  that  it  was  moderately 
well  nourished,  we  would  know  that  it  needed  50  calories  per 
pound  body  weight  in  twenty-four  hours.  This  would  make 
600  calories  of  food  which  this  infant  needs  to  maintain 
nutrition  and  gain  in  weight  (12  X  50  =  600).  Since  well 


60  SIMPLIFIED  INFANT  FEEDING 

infants  over  ten  pounds  in  weight  require  iy2  ounces  of 
sugar  in  the  twenty-four-hour  amount  of  food  (see  page  54) 
and  we  are  giving  plain  milk,  water  and  sugar  mixtures,  we 
find,  by  subtracting  the  caloric  value  of  this  1^  ounces  of 
sugar  (180  calories)  from  the  total  number  of  calories 
necessary,  that  420  calories  of  milk  must  be  given  (600- 
180  =  420).  This  420  calories  of  milk  (since  there  are  20 
calories  to  every  ounce  of  milk)  would  give  us  21  ounces 
of  milk  (420 -H  20  =  21).  Such  an  infant  then  needs  in 
twenty-four  hours  21  ounces  of  milk,  iy2  ounces  of  sugar. 
Assuming  for  the  moment  that  this  infant  could  take  42 
ounces  of  food  in  twenty-four  hours  (see  page  61),  sufficient 
water  must  be  added  to  make  up  the  42  ounces.  It  would 
then  be  made  up  in  the  following  manner : 

Milk,  21  oz 420  cals. 

Water,  21  oz. 

Sugar,  l]/j  oz 180  cals. 

600  total  calories  in  24  hours. 

As  a  second  example,  imagine  an  emaciated  infant,  five 
months  old,  weighing  seven  pounds,  who  has  no  digestive 
disturbances.  According  to  our  table  of  caloric  require- 
ments, this  infant  would  need  60  to  65  calories  per  pound. 
Since  this  infant  is  in  an  extreme  condition  of  emaciation, 
the  maximum  limit  of  food  value,  which  is  65  calories  per 
pound  in  twenty-four  hours,  should  be  given;  65  (cals.)  X 
7  (lbs.)=455  cals.,  total  number  of  calories  needed  in 
twenty-four  hours.  Of  this  total  455  calories,  120  calories 
may  be  given  in  the  form  of  sugar,  since  an  ounce  of  sugar 
may  be  given  in  twenty-four  hours;  455  - 120  =  335  calories 
of  milk  needed  in  twenty-four  hours.  Since  there  are  20 
calories  to  each  ounce  of  milk,  we  must  use  16!/o  ounces  of 
actual  milk  in  the  food  given  (335  -f-  20  =  16  -{- )  •  Assuming 
for  the  moment  that  this  infant  can  take  35  ounces  of  food 
in  twenty-four  hours,  sufficient  water  must  then  be  added 


FOOD  TO  SUPPLY  THE  CALORIC  NEEDS       61 

to  make  up  the  35  ounces.    We  will,  therefore,  disregarding 
the  fraction  of  an  ounce,  give  in  round  numbers : 

Milk,  17  oz 340  cals. 

Water,  18  oz. 

Sugar,     1  oz 120  cals. 

460  total  calories  in  24  hours. 

It  is  best  to  disregard  the  fractions  of  an  ounce,  because 
it  is  not  necessary  to  make  the  mother  go  to  the  trouble  of 
measuring  less  than  an  ounce,  and  so  small  a  deviation  from 
the  caloric  requirements  makes  no  difference  to  the  infant. 
It  is  also  usual  to  disregard  the  extra  bulk  (which  is  a  mere 
fraction  of  an  ounce)  which  the  dissolved  sugar  adds  to  the 
formula. 

Again  it  must  be  explained  that  if  the  infant  has  diar- 
rhoea, vomiting,  or  loss  of  appetite,  this  food  which  supplies 
its  actual  needs  will  only  serve  to  increase  these  symptoms 
and  should,  therefore,  not  be  given  until  such  symptoms 
have  first  been  successfully  treated.  Again  it  must  be 
emphasized  that  if  the  infant  has  not  been  receiving  sugar 
in  its  food,  or  has  been  getting  no  milk  or  much  smaller 
amounts  of  milk,  these  ingredients  must  be  increased  grad- 
ually, not  expecting  any  gain  in  weight  until  the  caloric 
needs  are  supplied. 

How  to  Determine  the  Quantity  of  Water. — The  quantity 
of  water  which  is  added  to  the  milk  and  sugar  depends  upon 
the  amount  of  food  that  the  infant  can  take  in  twenty-four 
hours;  that  is,  the  amount  of  milk  and  sugar  being  deter- 
mined, the  rest  of  the  food  must  necessarily  be  water.  There 
is  always  this  proviso :  an  infant  under  four  months  of  age 
or  one  that  has  recently  recovered  from  digestive  disturb- 
ances should  not  be  fed  with  a  stronger  dilution  than  half 
milk  and  half  water.  The  twenty-four-hour  quantity  of 
food  in  turn  depends  upon  the  number  of  ounces  that  an 
infant  may  take  at  one  feeding  and  the  number  of  feedings 


62  SIMPLIFIED  INFANT  FEEDING 

in  twenty-four  hours.  If  an  infant  can  take  six  ounces  at  a 
feeding,  seven  feedings  a  day,  the  twenty-four-hour  quantity 
will  be  42  ounces  (6  X  7  =  42). 

We  must,  therefore,  have  a  rule  for  the  quantity  that  may 
be  given  in  a  single  feeding  and  a  rule  for  the  number  of 
feedings  in  twenty-four  hours  which  will  apply  to  all  infants. 

How  to  Determine  the  Quantity  Given  in  a  Single  Feeding. — 
A  good  rule  for  the  quantity  to  be  given  at  a  single  feeding  is 
as  follows :  A  large  infant  or  an  infant  of  average  size  for  its 
age  should  have  at  each  feeding  one  or  two  ounces  more  tha/n 
the  number  of  months  of  its  age.  The  undersized  infant 
should  have  at  each  feeding  an  ounce  for  each  month  of  its 
age.  Sometimes  an  extremely  small,  undersized,  feeble  in- 
fant, perhaps  with  vomiting,  cannot  take  even  one  ounce 
for  each  month  of  age,  but  these  are  extreme  cases.  This 
rule  has  two  limitations,  the  first  concerning  the  minimum 
quantity  and  the  second  concerning  the  maximum  quantity 
that  any  infant  should  take.  (1)  It  is  never  necessary  to 
give  any  infant  more  than  eight  ounces  at  a  feeding,  or 
forty-eight  ounces  in  twenty-four  hours,  and  (2)  during 
the  first  weeks  of  life  the  quantity  at  each  feeding  should 
be  increased  as  rapidly  as  possible  up  to  three  or  four 
ounces  at  each  feeding,  the  guide  being  the  amount  that  the 
infant  will  take. 

It  will  be  seen  from  the  above  rules  that  the  quantity 
given  at  a  feeding  depends  chiefly  upon  the  infant's  age, 
although  some  allowance  is  made  for  its  size.  For  instance, 
the  average  sized  infant  of  four  months  of  age  should  be 
given  six  ounces  at  a  feeding.  The  undersized  infant  of 
that  age  should  not  be  given  any  more  than  four  ounces  at 
a  feeding,  while  the  extremely  small,  feeble  infant  of  four 
months,  weighing  only  five  or  six  pounds,  may  not  be  able 
to  take  more  than  three  ounces. 

The  quantity  that  an  infant  may  take  at  a  feeding  does 
not  depend,  as  formerly  thought,  upon  the  actual  holding 
capacity  of  the  stomach.  Since  it  takes  twenty  minutes  for 


FOOD  TO  SUPPLY  THE  CALOKIC  NEEDS       63 

the  average  infant  to  take  the  bottle,  a  large  part  of  the  food 
has  passed  out  of  the  stomach  through  the  pylorus  before 
the  feeding  is  finished,  so  that  the  stomach  never  has  to  hold 
at  any  one  time  all  the  food  given  at  a  single  feeding.  This 
has  been  determined  by  X-ray  experiments  and  is  an  estab- 
lished fact.  We  can  now  see  the  folly  of  measuring  post 
mortem  the  capacity  of  the  stomachs  of  infants  of  different 
ages,  as  was  formerly  done,  to  determine  the  amount  of  food 
that  might  be  taken  at  a  single  feeding. 

Number  of  Feedings  in  Twenty-four  Hours  and  the  Intervals 
between  Feedings. — There  is  a  great  difference  of  opinion 
concerning  the  length  of  time  that  should  elapse  between 
feedings.  Formerly  pediatricians  recommended  two-hour 
intervals  for  all  infants  under  four  months  of  age,  grad- 
ually increasing  the  intervals  after  this  age  up  to  three  hours 
between  feedings.  Others  use  four-hour  intervals  for  all 
infants  of  any  age,  sick  or  well,  and  are  particularly  insist- 
ent upon  the  four-hour  intervals  for  sick,  weakly  infants. 
The  author,  after  a  thorough  trial,  has  come  to  the  conclusion 
that  the  happy  medium  is  the  wisest  course.  The  three-hour 
intervals  from  6  A.M.  to  9  P.M.,  with  one  feeding  at  2  A.M. 
(seven  feedings  in  twenty-four  hours),  agree  with  most 
infants  up  to  three  or  four  months  of  age.  After  that  age, 
or  better  still,  when  the  infant  weighs  twelve  pounds,  the 
2  A.M.  feeding  should  be  omitted,  giving  six  feedings  in 
twenty-four  hours.  These  six  feedings  may  be  continued 
up  to  six  months  of  age  or  sixteen  pounds  in  weight,  when 
the  four-hour  intervals  are  best,  making  five  feedings  in  the 
twenty-four  hours. 

In  order  that  a  larger  twenty-four-hour  amount  and, 
therefore,  a  more  dilute  food,  may  be  given,  it  is  occasionally 
necessary  to  feed  once  in  two  hours  from  6  A.M.  to  10  P.M., 
with  one  feeding  at  2  A.M.,  giving  ten  feedings  in  twenty-four 
hours.  It  is  only  in  the  most  extreme  cases  of  undersized, 
feeble  or  premature  infants  weighing  less  than  five  pounds 
that  it  is  necessary  to  resort  to  these  two-hour  intervals. 


64  SIMPLIFIED  INFANT  FEEDING 

It  is  well  to  have  the  following  facts  on  the  tip  of  the 
tongue:  two-hour  intervals  with  one  night  feeding,  best 
coming  at  6,  8, 10, 12  A.M.,  2,  4,  6,  8, 10  P.M.  and  2  A.M.,  make 
ten  feedings  in  twenty-four  hours.  Three-hour  intervals 
with  one  night  feeding,  best  coming  at  6, 9, 12  A.M.,  3, 6, 9  P.M. 
and  2  A.M.,  make  seven  feedings  in  twenty-four  hours. 
Three-hour  intervals  without  any  night  feeding,  best  coming 
at  6,  9, 12  A.M.  and  3,  6,  9  P.M.,  make  six  feedings  in  twenty- 
four  hours.  Four-hour  intervals,  best  coming  at  6,  10  A.M., 
2,  6, 10  P.M.,  make  five  feedings  in  twenty-four  hours. 

One  may  then  know  at  a  glance  that  if  an  .infant  is  fed 
every  two  hours  with  one  night  feeding  and  is  getting  three 
ounces  at  a  feeding,  this  will  give  thirty  ounces  in  twenty- 
four  hours  (10  X  3  =  30).  Or,  for  instance,  an  infant  that 
is  being  fed  every  three  hours  with  one  night  feeding  is 
getting  seven  feedings  in  twenty-four  hours,  and  if  it  is 
capable  of  taking  six  ounces  at  a  feeding,  it  would  there- 
fore be  getting  forty-two  ounces  in  twenty-four  hours 
(7X6  =  42). 

CASE  VIII 

(Illustrating  the  method  of  feeding  an  infant,  using  caloric  requirements  as  a 
standard ) 

June  9:     Female,  age  2%  months.  Birth  weight,  6  Ib.  9  oz. 

Present  weight,  6  Ib.   15  oz. 
Gain    since    birth,    6    oz. 

General  Condition. — Emaciated,  undersized,  fair  color,  good  skin. 

Stools. — Three  normal  a  day. 

Vomiting. — None. 

Appetite. — Takes  all  her  food. 

Temperature,  98.6°  F. 

Bleep. — Good. 

Chief  Complaint. — Insufficient  gain  in  weight. 

Previous  Food: 

Milk    12  oz.,  240  cals.      Fed  3  oz.  every  2  hours,  10  feed- 
Water  18  oz.  ings  in  24  hours. 

Dextri-maltose.  %  oz.,     60  cals. 

Total  calories  given  300,  or  43  per  pound.    The  caloric  need  is  60  calories 
per  pound,  because  the  infant  is  emaciated. 


It  is  very  evident  that  this  infant  could  not;  possibly  gain  on  43  calories 
per  pound,  and,  in  order  to  fulfil  the  caloric  requirements,  more  milk  and  sugar 
must^  be  given.  There  was  no  vomiting  and  the  stools  were  normal,  so  that 
with  no  centra-indications  to  increasing  either  the  sugar  or  the  milk  (if  done 
gradually)  one  more  ounce  of  milk  was  added  each  day,  giving  one  ounce  less 
of  water,  until  the  24-hour  amount  of  food  was  15  oz.  milk  and  15  oz.  water 
boiled.  This  would  give  300  calories  of  milk.  At  the  end  of  that  time  the 
sugar  was  to  be  increased  %  oz.  every  third  day  until  1  ounce  ( 120  calories ) 
of  sugar  was  taken  in  twenty-four  hours.  The  total  number  of  calories  would 
then  be  420  (300  +  120  =  420),  and  as  the  infant  then  weighed  almost  7  Ib. 
this  would  give  60  calories  per  pound. 

June  30,  21  days  later:  Weight,  8  Ib. 

Gain,  1  Ib.  1  oz. 

General  Condition. — Much  improved. 
Stools. — Two  normal  a  day. 
Vomiting. — None. 
Appetite. — Still  hungry. 
Sleep. — Good. 

The  weight  had  increased  to  8  Ib.  and  the  infant  was  still  receiving  420 
calories  of  food,  making  only  52y2  calories  per  pound  per  day.  As  the  infant 
was  still  emaciated,  although  to  a  lesser  degree,  she  needed  60  calories  per 
pound,  or  480  calories  per  day  ( 8  X  60  =  480 ) . 

As  she  was  getting  the  maximum  amount  of  sugar  for  her  weight  ( 1  oz. 
for  infants  under  10  Ib.  ^  the  increase  had  to  be  made  in  the  form  of  milk. 

Treatment. — Food  prescribed : 

Milk 18  oz.,  \  360  cals.      Divide  into  7  feedings  of  3y2+ 

Water    18  oz.    (.  boiled  oz.  each.    Feed  every  2  hours 

Dextri-maltose .  .      1  oz.,  j  120  cals.          at  6,  9,  12  A.M.,  3,  6,  9  P.M., 

and  2  A.M. 

Total  calories  480,  or  60  per  pound. 

July   7,  7   days  later:  Weight,  8  Ib.  8  oz. 

Gain,  8  oz. 

General  Condition. — Much  improved. 
Stools. — Two  normal  per  day. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

At  the  present  weight,  with  the  food  prescribed  at  the  last  visit,  the  infant 

is  getting  56  calories  per  pound  per  day  (480  -4-  8.5  =  56).     With  this  gain  of 

weight  (1  Ib.  9  oz. )   since  July  9,  she  was  no  longer  emaciated  and  might  be 

classed  as  moderately  thin,  therefore  needing  50  to  55  calories  per  pound. 

5 


66 

As  she  was  already  getting  56  calories  per  pound  it  was  not  necessary  to  change 
the  food  until  a  further  gain  in  weight  was  made  and  the  number  of  calories 
per  pound  per  day  dropped  below  this  mark. 

July  29,  three  weeks  later:  Weight,  10  Ib. 

Gain,    1    Ib.    8   oz. 

General  Condition. — Well  nourished,  good  musculature. 
Stools. — Two  or  three  normal  stools  per  day. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 

The  infant  is  now  over  4  months  of  age  and,  although  short  in  stature, 
is  well  nourished  and  needs  only  50  to  55  calories  per  pound  per  day.  Since 
the  food  has  not  been  changed  with  her  increase  in  weight,  she  is  getting 
48  calories  per  pound  ( 480  ~  10  =  48 ) .  She  therefore  needs  more  food,  which 
may  be  given  in  the  form  of  sugar  (as  she  weighs  10  Ib.  and  can  be  allowed 
1%  oz.  of  sugar  in  24  hours). 

Treatment. — Food  prescribed : 

Milk    18  oz.  )  180  cale.       Divide  into  7  feedings  of  5+  oz.  each. 

iVater 18  oz.  |  boiled  Feed  at  6,  9,  12  A.M.,  3,  6.  9  P.M., 

Sugar   1%  oz.  360  cals.  and  2  A.M. 

Total  calories  540,  or  54  calories  per  pound. 

September  1,  four  weeks  later:  Weight,    12   Ib.    5   oz. 

Gain,  2  Ib.  5  oz. 
General  Condition. — Fat. 
Stools. — One  or  two  normal  a  day. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Fair. 

Since  the  food  has  not  been  changed  for  over  four  weeks  and  the  infant 
has  been  constantly  gaining  in  weight,  the  number  of  calories  per  pound  per  day 
has  dropped  from  54  to  45.  It  would  be  a  question  whether  she  was  fat  enough 
to  gain  on  45  calories  per  pound  or  not  (according1  to  our  table  of  caloric 
requirements ) . 

(540  cals.  -f-  12  Ib.  =  45  cals.  per  pound  per  day.) 

However,  she  has  not  gained  as  rapidly  in  the  last  week,  is  still  very  small 
for  her  age  (though  fat),  and  shows  signs  of  hunger  by  crying.  Taking  these 
facts  in  consideration,  we  should  still  give  50  calories  per  pound  per  day. 
Since  she  cannot  have  any  more  sugar,  it  is  necessary  to  make  the  increase  in 
the  form  of  milk.  As  620  calories  of  food  will  be  required  (12.4  X  50  =  620) 
and  180  calories  of  that  will  be  sugar,  it  will  leave  440  calories  (620-  180:= 
440)  or  22  ounces  (440-1-20  =  22)  to  be  supplied  in  milk. 


FOOD  TO  SUPPLY'THE  CALORIC  NEEDS   67 


Treatment. — Food  prescribed: 


boiled 


440  cals. 


Milk 22  oz.,  ) 

Water    . . .  20  oz.    } 

Sugar iy2  oz.,  180  cals. 

Total  calories  620,  or  50  calories  per  pound. 


Divide  into  6  feedings.  Feed  6  oz. 
every  3  hours  at  6,  9,  12  A.M.,  3,  6, 
9  P.M. 


The  physician  frequently  sees  an  infant  that  is  so  irregu- 
larly fed  that  it  is  impossible  to  determine  how  much  actual 
food  is  being  given  during  the  twenty-four  hours,  making 
it  quite  impossible  for  him  to  determine  the  caloric  value  of 
the  twenty-four-hour  amount  of  food  consumed. 

The  following  case  illustrates  very  well  this  phase  of 
infant  feeding: 

CASE  IX 

(Case  illustrating  the  necessity  of  an  accurate  and  routine  method  of  mixing 
and  administering  the  food) 

September  30 :     Male,  age  2  months.         Birth  weight,  6  Ib.  8  oz. 

Present  weight,  7  Ib.  13  oz. 
Gain  since  birth,  1  Ib.  5  oz. 

General  Condition. — Excellent. 

Stools. — Two  normal  with  cathartic. 

Vomiting. — None. 

Appetite. — Good,  takes  all  the  food. 

Temperature,  98.6°  F. 

Sleep. — Good. 

Chief  Complaint. — Fretful  and  not  gaining  in  weight. 


Previous  Food: 

Milk 1  cup 

Water    2  cups 

Barley    1  tablespoonf ul 

Cane  sugar  1  tablespoonf  ul 


unboiled 


The  barley  was  boiled  for  five  minutes, 
then  the  milk  was  poured  into  the 
gruel  and  brought  to  a  boil.  Food 
was  made  two  or  three  times  in  24 
hours,  or  whenever  more  food  was 
needed.  4  to  6  oz.  (as  much  as  the 
baby  would  take)  was  given  once  in 
two  to  four  hours  or  whenever  the 
baby  cried. 

It  is  impossible  to  reckon  the  calories  in  this  food,  because  the  size  of  the 
cups  is  not  known,  and  it  is  also  impossible  to  ascertain  the  quantity  of  food 
taken  in  twenty-four  hours. 


68  SIMPLIFIED  INFANT  FEEDING 

Treatment. — The  mother  was  instructed  to  buy  a  cheap  glass  graduate  and  to 
purchase  at  least  7  nursing  bottles,  marked  off  in  ounces  (when  it  is  not 
possible  to  purchase  graduates,  the  ingredients  of  the  food  may  be  measured 
in  the  nursing  bottles),  and  two  or  three  nipples.  She  was  told  to  make 
the  food  at  the  same  time  each  day  in  the  following  manner: 

Milk  16  oz.,  )  320  cals.      Divide  into  7  feedings.     Feed  4+ 

Wator   16  oz.    J  ^ned  oz.  every  3  hours  at  6,  9,  12  A.M., 

Cane  sugar  . .     1  oz.,  120  cals.          3,  6,  9  P.M.,  and  2  A.M. 

(2  level  tablespoonfuls) 
Total  calories  440,  or  55  calories  per  pound. 

The  infant  did  well  upon  these  feedings  and  gained  continuously  in  weight 
as  the  food  was  increased  in  proportion  to  the  gain  in  weight. 

Mothers  are  usually  glad  of  suggestions.  They  realize 
that  their  work  is  made  much  easier  for  them  by  doing 
things  upon  a  schedule,  and  that  the  entire  care  of  the  infant 
is  lessened  thereby.  Even  among  dispensary  patients  it  is 
rare  to  meet  with  any  objection  to  such  a  plan  of  treatment. 

The  feeding  of  the  new-born  infant  from  birth  and 
throughout  the  first  two  weeks  of  life  has  been  described 
elsewhere  (see  page  75).  As  has  been  said  there,  at  two 
or  three  weeks  of  age  the  average  infant's  formula  would 
have  been  gradually  increased  to  fifteen  ounces  of  milk, 
fifteen  ounces  of  water  and  one  ounce  of  sugar  (four  level 
tablespoonfuls  of  malt  sugar,  three  tablespoonfuls  of  milk 
sugar  or  two  tablespoonfuls  of  cane  sugar).  An  infant  of 
this  age  will  weigh  seven  or  eight  pounds.  In  this  formula 
there  are  300  calories  of  milk  and  120  calories  of  sugar,  420 
calories  in  all.  An  eight-pound  infant  would,  therefore, 
receive  fifty-two  calories  per  pound  per  day,  and  a  seven- 
pound  infant  would  be  getting  sixty  calories  per  pound  per 
day.  In  either  case  this  formula  fulfils  the  caloric  require- 
ments, because  a  seven-pound  infant  of  two  weeks  of  age  is 
usually  not  a  fat  infant  and  needs  sixty  calories  per  pound, 
while  an  eight-pound  infant  of  this  age  is  fairly  well  nour- 
ished and  would  gain  very  nicely  on  fifty  to  fifty-five  calories 
per  pound  per  day. 

As  the  infant  grows  and  gains  in  weight,  the  milk  and 


FOOD  TO  SUPPLY  THE  CALORIC  NEEDS       69 

water  should  be  increased  an  ounce  at  a  time,  always  keeping 
the  food  equal  parts  of  milk  and  water  up  to  twenty  ounces 
of  each.  That  is,  the  next  change  would  be  sixteen  ounces 
of  water  and  one  ounce  of  sugar,  then  seventeen  ounces  of 
milk,  seventeen  ounces  of  water  and  one  ounce  of  sugar  and 
so  on  up  to  twenty  ounces  of  milk,  twenty  ounces  of  water 
and  one  ounce  of  sugar. 

The  sugar  should  not  be  increased  above  one  ounce  a  day 
until  the  infant  has  reached  ten  pounds  in  weight  (see  page 
54),  when  it  may  be  gradually  increased  to  one  and  a  half 
ounces  for  the  total  twenty-four-hour  amount  of  food.  With 
the  increase  in  sugar  the  formula  will  be  twenty  ounces  of 
milk,  twenty  ounces  of  water  and  one  and  a  half  ounces 
of  sugar. 

If  we  now  take  account  of  calories  we  find  that  there  are 
400  calories  of  milk  and  180  calories  of  sugar,  making  580 
calories  in  all,  which  for  a  ten-pound  baby  would  give  58 
calories  per  pound  per  day,  or  for  an  eleven-pound  baby 
about  53  calories  per  pound  per  day.  This  as  a  rule  works 
out  very  nicely,  because  if  the  baby  is  fat  and  well  nourished 
he  will  need  only  53  calories,  while  if  he  is  thinner  he  would 
need  the  58  calories.  ( See  page  58. ) 

In  the  meantime,  the  total  amount  of  food  has  always 
been  equally  divided  into  seven  bottles,  fed  at  six,  nine  and 
twelve  A.M.  and  three,  six  and  nine  P.M.  and  two  A.M.  After 
the  baby  has  reached  twelve  pounds  in  weight,  the  two  A.M. 
feeding  may  be  discontinued  and  the  total  amount  of  food 
divided  evenly  into  six  bottles. 

Later,  when  the  infant  has  again  increased,  in  weight, 
and  therefore  requires  more  food  to  fulfil  the  caloric  require- 
ments, it  is  necessary  to  begin  increasing  the  food  once  more. 
The  food  can  now  be  made  stronger  than  half  milk  and 
half  water,  because  the  infant  is  over  twelve  pounds  in  weight 
and  is  three  or  four  months  of  age  (see  page  61).  From 
now  on  the  milk  should  lie  increased  without  increasing 


70  SIMPLIFIED  INFANT  FEEDING 

the  water,  and  the  next  change  therefore  would  be  to  twenty- 
two  ounces  of  milk,  twenty  ounces  of  water  and  one  and  a 
half  ounces  of  sugar  divided  evenly  into  six  bottles.  This 
change  suffices  for  a  time  until  the  infant  has  gained  suffi- 
ciently in  weight  to  the  point  where  this  amount  of  food 
does  not  fulfil  the  caloric  requirements.  Then,  still  in- 
creasing the  milk  without  increasing  the  water,  we  get  up 
to  twenty-four  ounces  of  milk,  twenty  of  water  and  one 
and  a  half  ounces  of  sugar.  The  next  change  would  be 
twenty-six  ounces  of  milk,  twenty  ounces  of  water  and  one 
and  a  half  ounces  of  sugar,  the  next  change  twenty-eight 
ounces  of  milk,  twenty  ounces  of  water  and  one  and  a  half 
ounces  of  sugar.  Again  taking  account  of  the  calories  we 
have  560  calories  of  milk,  180  calories  of  sugar,  making 
740  calories  in  all.  Thus  a  fifteen-pound  baby  would  get 
about  fifty  calories  per  pound  or  a  sixteen  and  a  half  pound 
baby  forty-five  calories  per  pound.  The  infant,  which  would 
probably  be  about  six  months  of  age,  would  need  fifty  calor- 
ies if  it  weighed  fifteen  pounds,  but  if  it  were  fat  and 
weighed  between  sixteen  and  seventeen  pounds  forty-five 
calories  would  be  ample. 

Before  a  further  increase  is  necessary,  it  is  best  to  cut 
down  the  number  of  feedings  to  five  in  the  twenty-four 
hours,  and  start  upon  a  four-hour  schedule,  the  feedings  com- 
ing at  6  and  10  A.M.,  2,  6  and  10  P.M.  If  we  were  to 
divide  the  twenty-eight  ounces  of  milk  and  twenty  ounces  of 
water  evenly  into  five  feedings,  it  would  give  us  nearly  ten 
ounces  in  each  bottle,  which  is  usually  too  much,  so  that  it 
is  now  found  practicable  to  give  a  stronger  dilution  by 
cutting  down  the  water  and  not  giving  more  than  eight  ounces 
at  a  feeding.  Allowing  for  the  food's  decrease  in  volume 
by  the  active  boiling  of  three  minutes,  we  will  get  eight  ounces 
at  a  feeding  by  using  the  following  formula :  milk  twenty- 
eight  ounces,  water  fourteen  ounces,  sugar  one  and  a 
half  ounces. 


From  now  on  the  water  should  be  decreased  as  the  milk 
is  increased,  making  an  even  stronger  dilution.  As  the 
infant  is  presumably  seven  or  eight  months  of  age  by  this 
time  and  the  weight  has  increased  up  to  seventeen  or  eighteen 
pounds,  the  next  change  in  the  formula  would  be  to  thirty 
ounces  of  milk,  twelve  ounces  of  water  and  one  and  a  half 
ounces  of  sugar.  Still  later  increase  the  milk  to  thirty-two 
ounces,  water  ten  ounces  and  sugar  one  and  one-half  ounces. 
We  are  now  giving  a  full  quart  of  milk  in  twenty-four  hours 
and  that  is  as  much  milk  as  any  normal  infant  needs.  If 
we  again  take  account  of  the  calories,  the  thirty-two  ounces 
of  milk  equals  640  and  the  one  and  one-half  ounces  of  sugar 
180  calories,  making  a  total  of  820  calories  in  the  day 's  food. 
With  this  mixture  an  eighteen-pound  baby  would  be  getting 
forty-five  calories  per  pound  per  day. 

From  now  on  we  must  add  other  foods  besides  milk  and 
sugar,  when  it  becomes  necessary  to  increase  the  number  of 
calories  as  the  infant  increases  in  weight.  Barley  gruel 
should  be  used  as  the  diluent  instead  of  water,  if  the  infant  is 
under  seven  and  one-half  months  of  age,  which  is  rare  indeed. 
After  this  age  the  number  of  calories  may  be  increased  by 
giving  breadstuff's,  cereals  and  gruels  in  addition  to  the 
bottle  feedings.  The  cereals  and  gruels  should  be  fed  with 
a  spoon,  and  the  breadstuffs  given  dry  in  the  hand  so  that 
the  infant  may  learn  to  eat,  and  should  be  varied  from  day 
to  day,  so  that  the  infant  will  like  a  variety  of  food.  They 
should  never  be  given  between  feedings,  but  immediately 
before  a  bottle  feeding.  After  the  infant  has  become  accus- 
tomed to  eating  these  foods,  it  is  time  to  change  gradually 
to  a  diet  of  undiluted  milk  and  cereals,  as  shown  on  page 
319,  in  Case  LXXX. 

All  through  this  feeding  period  it  is  the  author's  custom 
to  boil  the  milk.  He  has  found  that  so  many  babies  have 
digestive  disturbances  when  it  is  attempted  to  stop  boiling 
the  milk,  and  things  go  along  so  smoothly  when  the  boiled 


72  SIMPLIFIED  INFANT  FEEDING 

milk  is  used  throughout  the  bottle  period,  that  there  is  sel- 
dom any  reason  for  attempting  to  change  to  raw  milk. 

Orange  juice  should  be  given  to  the  normal  bottle-fed 
infant  at  six  weeks  to  two  months  of  age,  beginning  with  a 
teaspoonful  once  a  day,  one  hour  before  a  feeding,  preferably 
at  8  A.M.  If  the  orange  juice  agrees,  it  should  be  increased 
a  teaspoonful  each  week.  That  is,  the  second  week  two  tea- 
spoonfuls  should  be  given  each  day  at  8  A.M.  and  the  third 
week  three  teaspoonfuls,  and  so  on,  until  in  two  or  three 
months  the  juice  of  a  whole  orange  is  given  once  a  day  an 
hour  before  a  feeding.  When  orange  juice  was  first  used 
as  a  routine  with  boiled  milk  mixtures,  all  it  was  meant 
to  do  was  to  prevent  scurvy.  In  the  author's  opinion  there 
is  no  question  but  that  it  does  a  great  deal  more  than  this. 
In  case  after  case  it  has  been  observed  that  the  infants  that 
take  a  lot  of  orange  juice  and  take  it  well  are  the  infants  who 
thrive  the  best.  They  gain  faster,  the  color  of  the  cheeks^ 
mucous  membranes  and  lips  is  rosier,  the  muscles  and  the 
flesh  are  firmer,  the  skin  more  smooth  and  velvety,  the  hair 
silky  and  the  bones  well  shaped.  Infants  who  do  not  take 
orange  juice  well  and  in  large  quantities  are  less  apt,  as  time 
goes  on,  to  present  this  healthful  appearance.  It  is  true  that 
all  babies  do  not  take  orange  juice  well,  and  with  those  who 
do  not  it  is  necessary  to  proceed  very  cautiously  in  increas- 
ing the  amount.  Occasionally  infants  have  loose  undi- 
gested stools  when  orange  juice  is  given,  or  have  colic  or 
vomiting.  Such  infants  are  by  far  in  the  minority  and  they 
are  usually  difficult  infants  to  feed.  The  author  has  seldom 
found  that  any  other  antiscorbutics  are  better  borne,  but 
potato  water  or  the  juice  from  canned  tomatoes  may  be  tried 
when  orange  juice  seems  to  disagree. 


It  will  be  seen  from  the^preceding  pages  on  calories  that 
an  infant  requires  a  definite  number  of  ounces  of  milk  every 


FOOD  TO  SUPPLY  THE  CALORIC  NEEDS       73 

day  for  each  pound  of  body  weight,  to  which  is  added  one 
or  one  and  a  half  ounces  of  sugar.  This  milk  and  sugar 
must  be  diluted  with  water.  A  rough  rule  for  estimating  the 
quantity  of  cow's  milk  that  an  infant  needs  is  as  follows: 
The  average  infant  having  no  digestive  disturbances  re- 
quires in  twenty-four  hours  twice  as  many  ounces  of  milk 
as  it  weighs  in  pounds,  provided  it  can  take  one  or  one  and 
a  half  ounces  of  sugar.  Fat,  well-nourished  infants,  older 
than  four  months,  need  less  than  this,  while  emaciated  in- 
fants often  need  much  more.  For  an  illustration,  take  an 
infant  weighing  10  pounds;  this  infant  would  require  20 
ounces  of  milk  (since,  according  to  the  rule,  it  needs  twice 
as  many  ounces  of  milk  as  it  weighs  in  pounds)  and  per- 
haps 20  ounces  of  water,  and  if  an  ounce  of  sugar  were  added 
to  this,  it  would  give  520  calories  (20  X  20  =  400 ;  400  +  120 
=  520).  This  infant  would  then  be  getting  52  calories  per 
pound  (520-^10  =  52).  This  is  about  the  caloric  require- 
ment for  the  average  infant  under  four  months  of  age. 
This  rule,  it  must  be  remembered,  applies  to  the  well  infant 
only.  It  would  be  disastrous  to  give  an  infant  who  has 
diarrhea,  vomiting,  or  other  digestive  disturbances  the  pre- 
scribed number  of  calories  of  milk  and  sugar,  though  it  can- 
not be  expected  to  gain  in  weight  until  the  required  amount 
can  be  given.  When  there  are  such  digestive  disturbances, 
food  which  may  not  so  well  fill  the  infant's  caloric  require- 
ments must  be  used  temporarily.  The  reasons  for  this  and 
the  proper  method  of  gradually  increasing  the  milk  and 
sugar  are  discussed  fully  in  the  following  chapter. 


CHAPTER  VI 

CONDITIONS  UNDER  WHICH  THE  CALORIC  RE- 
QUIREMENTS SHOULD  NOT  BE  FULFILLED 

ONE  of  the  first  principles  of  caloric  feeding  is  not  to 
fulfil  the  caloric  requirements  in  certain  classes  of  infants. 
Those  who  are  opposed  to  caloric  infant  feeding  do  not  seem 
to  realize  this,  and  base  their  criticism  upon  the  supposition 
that  all  infants  at  all  times  are  fed  according  to  their  actual 
caloric  needs. 

Usually  it  is  extremely  harmful  to  start  an  infant  with 
a  food  of  the  full  strength,  and  to  give  the  required  amount 
of  milk  and  sugar  to  make  up  the  number  of  calories  which 
we  know  must  eventually  be  given  to  make  the  infant  gain 
in  weight  and  develop  properly.  For  instance,  an  infant 
comes  for  treatment  who  is  to  be  fed  artificially  for  the  first 
time,  perhaps  through  a  sudden  cessation  of  the  breast  milk. 
We  would  have  a  very  sick  infant  on  our  hands  if  we  at- 
tempted immediately  to  fill  its  caloric  requirements.  There 
are  certain  indications  for  increasing  an  infant's  tolerance 
before  the  caloric  needs  can  be  fulfilled. 

The  caloric  requirements  should  not  be  fulfilled  under 
the  following  conditions : 

(1)  In  the  new-born  (for  the  first  two  weeks). 

(2)  Normal  infants  abruptly  weaned  from  the  breast 
(until  their  tolerance  for  food  can  be  gradually  increased). 

(3)  Infants    whose  previous   food  has   not   contained 
cow's  milk   (until  the  milk  and  sugar  can  be  gradually 
increased). 

(4)  Infants  who  have  been  overfed  (until  their  digestive 
apparatus  has  had  a  chance  to  recuperate). 

(5)  Infants  who  have  been  underfed  (until  their  toler- 
ance for  food  has  been  gradually  increased). 

74 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  75 

(6)  Infants  who  have  diarrhoea  or  who  have  recently 
recovered  from  diarrhoea   (until  the  stools  have  become 
normal  and   the  tolerance  for  food  has  been  gradually 
increased). 

(7)  Infants  who  have  excessive  vomiting  or  have  re- 
cently recovered  from  excessive  vomiting  (until  vomiting 
has  stopped  and  the  tolerance  for  food  increased). 

(8)  Infants   with  loss   of  appetite    (until  all   food   is 
greedily  taken). 

(9)  Infants  who  are  partially  breast  fed  (until  they  are 
entirely  weaned,  because  it  is  impossible  to  determine  how 
many  calories  they  are  getting  from  the  breast). 

NEW-BORN  INFANTS 

Occasionally  an  infant  has  to  be  bottle-fed  from  birth 
through  the  sudden  death  or  illness  of  the  mother,  or  through 
the  certainty  that  the  mother  cannot  supply  sufficient  milk 
to  nourish  it  (see  Breast  Feeding,  page  220).  When  such 
an  occasion  arises,  it  is  most  essential  to  avoid  giving  too 
strong  a  food  during  the  first,  second,  and  third  weeks  of 
life.  Considering  the  fact  that  many  breast-fed  infants  do 
not  show  a  gain  in  weight  during  the  first  ten  days  or  two 
weeks  of  life,  bottle-fed  infants  should  not  be  expected  to 
do  any  better.  Begin,  therefore,  on  weak  foods  which  do  not 
come  up  to  the  caloric  requirements ;  and  increase  the  toler- 
ance by  gradually  increasing  the  strength  of  the  food  until 
the  infant  is  getting  enough  milk  and  sugar  in  twenty-four 
hours  to  fill  its  caloric  requirements  and  to  permit  of  a  gain. 

For  the  first  week,  twenty  ounces  of  food  may  be  mixed 
each  day,  offering  the  infant  three  ounces  every  three  hours 
(seven  feedings  in  twenty-four  hours).  At  first  less  than 
an  ounce  will  be  taken  at  a  time,  but  the  infant  is  allowed  all 
that  it  will  take  of  three  ounces,  the  remainder  being  thrown 
away.  This  food  should  be  made  one-quarter  milk  and 
three-quarters  water, — that  is,  five  ounces  of  milk  and  fifteen 


76  SIMPLIFIED  INFANT  FEEDING 

ounces  of  water.  The  milk  and  water  should  be  boiled  to- 
gether during  the  first  month  or  two  of  the  infant's  life. 
No  sugar  should  be  added  until  the  stools  have  become  firm 
and  smooth  and  yellow,  showing  no  traces  of  mucus. 

At  the  end  of  four  or  five  days,  or  when  the  infant  takes 
all  of  the  three  ounces  offered,  begin  to  increase  the  strength 
of  the  food.  This  is  accomplished  by  adding  an  ounce  more 
of  milk  each  day,  or  on  alternate  days,  allowing  the  amount 
of  water  to  remain  stationary.  The  first  day  of  the  increase, 
six  ounces  of  milk  are  added  to  the  fifteen  ounces  of  water ; 
the  next  day  seven  ounces  of  milk  to  fifteen  ounces  of  water, 
and  so  on.  With  this  increase  in  the  strength  of  the  mixture 
the  milk  is  gradually  changed  from  one-quarter  to  one-third 
milk  in  proportion  to  the  amount  of  water,  and  by  the  end 
of  the  second  week,  if  the  milk  is  increased  one  ounce  each 
day,  the  infant  will  be  getting  half  milk  and  half  water,  or 
fifteen  ounces  of  milk  and  fifteen  ounces  of  water.  This  is 
as  strong  a  dilution  as  it  is  advisable  to  give  an  infant  under 
three  or  four  months  of  age. 

The  quantity  given  at  each  feeding  is  at  the  same  time 
being  gradually  increased,  since  the  whole  amount  of  food 
made  each  day  is  divided  into  seven  bottles.  When  the  half- 
and-half  mixture  has  been  reached  (fifteen  ounces  of  milk 
and  fifteen  ounces  of  water)  there  will  be  a  little  over  four 
ounces  in  each  bottle,  some  of  the  water  being  boiled  away. 

In  the  meantime  the  sugar  has  been  added  and  gradually 
increased  in  the  following  manner:  when  the  meconium 
has  disappeared  and  the  stools  have  become  firm,  smooth, 
yellow,  and  free  of  mucus,  one  level  tablespoonful  of  sugar 
(levelled  with  a  knife)  is  added  to  the  whole  twenty-four- 
hour  amount  of  food.  If,  after  three  or  four  days,  the  stools 
remain  firm  with  this  amount  of  sugar,  two  level  tablespoon- 
fuls  are  used.  Three  or  four  days  later  the  sugar  is  again 
increased  by  one  level  tablespoonful  and  so  on  up  to  one 
ounce  of  sugar  in  twenty-four  hours,  which  is  as  much  as  any 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  77 

infant  under  ten  pounds  in  weight  should  receive.  In  in- 
creasing the  sugar,  always  be  guided  by  the  bowels.  If  they 
become  in  the  least  loose  or  show  signs  of  indigestion,  it  is 
better  not  to  further  increase  the  sugar  until  these  signs  have 
disappeared.  If  there  is  constipation,  the  sugar  may  be 
increased  a  teaspoonful  each  day,  avoiding  cathartics  and 
giving  an  enema  once  in  twenty-four  hours  if  the  bowels  will 
not  move  without  it. 

This  method  of  feeding  may  be  used  at  any  time  during 
the  first  two  or  three  weeks  of  life  if  bottle  feedings  have 
to  be  instituted. 

CASE  X 

Owing  to  the  fact  that  three  previous  children  of  this  mother  had  suffered 
a  severe  initial  loss  in  weight  and  strength,  through  the  unsuccessful  endeavor 
to  feed  from  her  breast,  it  was  decided,  even  before  the  birth  of  this  infant,  to 
give  artificial  feedings  from  the  start.  Under  the  most  ideal  conditions  as  to 
diet,  rest  and  good  health,  the  mother  had  had  almost  no  breast  milk  after  the 
three  former  confinements. 

November  20:     Age,  1  day.  Weight,   6   Ib.    12   oz. 

General  Condition. — That  of  a   small  new-born   infant   somewhat  under  the 

average. 

Stools. — Meconium. 
Vomiting. — None. 
Appetite. — Takes  nipple  well. 
Sleep. — Good. 

Treatment. — Food  prescribed: 

Milk   5  oz.  )       .        (100  cals.)       Divide  into  7  feedings.     Feed  1  to  2 

Water    15  oz.  [  b  oz.  every  3  hours,  at  6,  9,  12  A.M., 

Sugar 0  3,  6,  9  P.M.,  2  A.M. 

November   21    (1    day   later)  :       Age,  2  days.     Weight,  6  Ib.  9  oz. 

Loss,  3  oz. 

General  Condition  as  at  the  last  visit. 
Stools. — Meconium. 
Vomiting. — None. 

Appetite. — Takes  %  to  %  oz.  at  a  feeding. 
Sleep. — Good. 

Treatment . — Food  prescribed : 

Milk 5  oz.  )       .          (100  cals. )       Divide  into  7  feedings.    Feed  1  to  3 

Water 15  oz.  j  ^iled  oz  every  3  hour8j  at  6(  9>  12  A-Mi> 

Sugar    0  3,  6,  9  P.M.,  2  A.M. 


78  SIMPLIFIED  INFANT  FEEDING 

November  24   (3  days  later):    Age,  5  days.    Weight,  6  Ib.  9  oz. 
General  Condition. — Good. 
Stools. — Three  firm,  no  mucus. 
Vomiting. — None. 

Appetite. — Takes  whole  3  oz.  at  each  feeding. 
Sleep. — Good. 
Treatment. — Food  prescribed:  Increase  the  milk  1  oz.  each  day  up  to: 

Milk 8  oz.    )  (160  cals.)       Divide  into  7  feedings.    Feed 

Water    15  oz.   [  boiled  3  oz.  every  3  hours,  at  6,  9, 

Dextri-maltose.  .  .    %  oz.  (30  cals.)  12  A.M.,  3,  6,  9  P.M.,  2  A.M. 

Total  number  of  calories  190,  or  30  calories  per  pound.     Caloric  require- 
ments, 55  per  pound. 

November  27    (3  days  later):     Age,   8  days.     Weight,  6  Ib.  11  oz. 

Gain,  2  oz. 

General  Condition. — Good. 

Stools. — Three  normal,  except  for  small  amount  of  mucus. 
Vomiting. — None. 

Appetite. — Satisfied,  takes  all  the  food. 
Sleep. — Poor  at  night 

Treatment. — Food  prescribed:  Increase  the  milk  1  oz.  each  day  up  to: 

Milk 12  oz.  )       .          (240  cals.)       Divide  into  7  feedings  of  3% 

Water    15  oz.  j  b°l1  oz.     Feed  at  6,  9,  12  A.M., 

Dextri-maltose    ..    %  oz.  (30  cals.)          3,  6,  9  P.M.,  and  2  A.M. 

Total  number  of  calories  27  G,  or  40  calories  per  pound. 

December  2  (5  days  later)  :     Age,  13  days.     Weight,    6    Ib.    11    oz. 

No  gain. 

General  Condition. — Gdx>d. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk 14  oz.    |      .         (280  cals.)      Divide  into  7  feedings  of  4  oz. 

Water    15  oz.   J  b  each.    Feed  as  before. 

Dextri-maltose  ...   %  oz.  (30  cals.) 

Total  number  of  calories  310,  or  45  calories  per  pound. 

December  4  (2  days  later)  :     Age,  15  days.     Weight,  7  Ib. 

Gain,  5  oz. 

General  Condition. — Good. 
Stools. — Two  hard,  dry,  yellow,  homogeneous. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  79 

Treatment. — Food  prescribed : 

Milk 15  oz.  )  (300  cals.)       Divide  into  7  feedings  of  4-+- 

Water    15  oz.  £  oz.  each.     Feed  as  before. 

Dextri-maltose    .  .    %  oz-  (60  cals.) 

Total  number  of  calories  360,  or  51-f-  calories  per  pound. 
December  7   (3  days  later)  :     Age,  18  days.     Weight,  7  Ib.  2  oz. 

Gain,  2  oz. 

General  Condition. — Good. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk    15  oz.   >       .          (300  cals.)       Divide  into  7  feedings  of  4-j- 

Water    15  oz.  f  oz.  each.     Feed  as  before. 

Dextri-maltose    ..   %  oz.  (90  cals.) 

Total  number  of  calories  390,  or  56-  calories  per  pound. 

December  12  (5  days  later)  :     Age,  23  days.     Weight,  7  Ib.  8  oz. 

Gain,  6  oz. 

General  Condition. — Good. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 

Treatment. — Food  prescribed: 

Milk    15  oz.   )  (300  cals.)       Divide  and  feed  as  before. 

TUT  A  i  -          f  boiled 

Water    la  oz.   I 

Dextri-maltose...      1  oz.  (120  cals.) 

Total  number  of  calories  420,  or  56  calories  per  pound. 

December  20  (8  days  later)  :     Age,  1  month.     Weight,  8   Ib. 

Gain,  8  oz. 

General  Condition. — Good. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Satisfied. 
Sleep. — Good. 

CASE  XI 

(Illustrating  the  method  of  feeding  an  infant  three  days  old> 
May  23 :     Age,  3  days.     Birth  weight,   7  Ib.  7  oz. 
Present  weight,  7  Ib. 
Loss  since  birth,  7  oz. 


80 


SIMPLIFIED  INFANT  FEEDING 


General  Condition. — Well  nourished,  normal  in  every  way. 

Stools. — Meeonium  just  disappearing  and  stools  beginning  to  get  green  and 

watery,  with  some  mucua,  owing  to  underfeeding  during  the  first  days  of  life. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 
Previous  Food. — Has  been  put  to  the  breast  once  in  four  hours  since  birth. 

On  the  third  day,  through  illness  of  the  mother,  it  was  found  necessary  to 

give  artificial  feeding. 
Treatment. — Food  prescribed: 

Milk   5  oz.  )  (100  cals.)       Divide  into  7  feedings  of  3  oz.  each. 

Water 15  oz.  f  boiled  Feed  1  to  3  oz.  every  3  hours  at  6, 

.Sugar 0  9,  12  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

May   25    (2    days    later)  :     Age,   5   days.     Weight,  7  Ib. 

No  gain  or  loss. 

General  Condition. — The  same. 

Stools. — Three  yellow  and  smooth  daily,  with  no  mucus  or  curds. 
Vomiting. — None. 

Appetite. — Hungry;  takes  3  oz.  at  a  feeding. 
Sleep. — Good. 
Treatment. — Food  prescribed: 

Milk  6  oz.  )  (120  cals.)      Divide  into  7  feedings  and  feed  as 

Water    ....   15  oz.  f  b  before. 

Sugar 0 

The  milk  was  to  be  increased  one  ounce  each  day  and  dextri-maltose  added 
a  tablespoonful  more  every  third  day  so  that  by  June  3,  when  the  infant 
was  fifteen  days<  old,  the  formula  was  as  follows: 

Milk 15  oz.  )  (300  cals.)      Divide  into   7  feedings   and 

Water    15  oz.  }  b  feed  as  before. 

Dextri-maltose. . .    %  oz.  (60  cals.) 

Total  calories  360,  or  51  calories  per  poiind. 
per  pound. 

Age,   15   days. 


Caloric  requirements,  55 


June   3    (7   days   later)  : 

General  Condition. — Excellent. 

Stools. — Two  soft,  smooth,  yellow. 

Vomiting. — None. 

A  ppetite. — Hungry. 

Sleep. — Good. 

Treatment . — Food  prescribed : 

Milk    15  oz.  ) 

Water    15  oz.  f  boiled 

Dextri-maltose. .  .         oz. 


Weight,  7  Ib.  6  oz. 
Gain,  6  oz. 


(300  cals.) 
(90  cals.) 


Divide  into  7  feedings  and 
feed  as  before. 


Total  number  of  calories  390,  or  52  per  pound. 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  81 

June  10  (7  days  later)  :     Age,  21  daya.     Weight,  7  Ib.  10  oz. 

Gain,  4  oz. 

General  Condition. — As  at  last  date. 
Stools. — Two  yellow,  smooth,  with  no  mucus  or  curds. 
Vomiting. — None. 
Appetite. — Takes  all  the  food. 
Sleep. — Good. 

Treatment. — Food  prescribed: 

Milk 15  oz.  )       .         (300  cals.)       Divide  into  7   feedings   and 

Water    15  oz.  j  b  feed  as  before, 

Dextri-maltose .  .  .      1  oz.  (120  cals.) 

Total  number  of  calories  420,  or  55  calories  per  pound. 

The  caloric  requirements  now  being  filled,  the  infant  continued  to  gain 
in  weight  as  the  food  was  increased,  and  at  seven  months  of  age  the  weight 
was  20  pounds.  The  milk  was  boiled  during  the  first  six  weeks,  after  *vhich 
it  was  changed  to  raw  milk  mixtures  without  any  digestive  disturbance. 

NORMAL  INFANT  ABRUPTLY  WEANED  FROM  THE  BREAST 

It  occasionally  happens  that  a  normal,  healthy  infant 
must  be  abruptly  weaned  from  the  breast  on  account  of  the 
mother's  ill-health  or  death,  or  for  some  other  unavoidable 
reason.  No  matter  what  the  age  of  the  infant  when  bottle 
feeding  is  begun,  a  food  much  weaker  than  is  sufficient  to 
supply  the  infant's  caloric  requirements  must  be  used  at 
first.  Older  infants  may  have  the  food  increased  more 
rapidly  than  younger  ones,  but  it  is  advisable  at  any  age 
to  begin  with  one-third  milk  and  two-thirds  water,  and  with  a 
very  small  amount  of  sugar.  It  is  also  preferable  to  boil  the 
milk  for  the  first  few  weeks.  Infants  who  have  never  had 
any  cow's  milk  will  usually  stand  boiled  milk  better  at  first, 
and  the  strength  of  the  food  can  be  increased  more  rapidly 
than  with  raw  milk. 

CASE  XII 
( Illustrating  abrupt  weaning  of  an  infant  on  account  of  mother's  sudden  death ) 

January  28:     Age,  2  months.     Birth  weight,  6  Ib.  8  oz. 

Present  weight,  9  Ib.  14  oz. 
:Gaih  since  birth,  3  Ib.  6  oz. 


82  SIMPLIFIED  INFANT  FEEDING- 

General  Condition.  —  Excellent;  fat,  well  nourished,  normal  in  every  way. 
Stools.  —  Two  normal  a  day. 
Vomiting.  —  None. 
Appetite.  —  Normal. 
Sleep.  —  Good. 

Previous  Food.  —  Has  never  had  anything  but  breast  milk,  which  was  given 
every  3  hours,  7  feedings  in  24  hours,  until  the  sudden  death  of  the  mother 
the  night  before. 

Treatment.  —  Food  prescribed  : 

Milk  ............    10  oz.          .         (200  cals.)       Divide  into  7  feedings  of  4-f 


. 
Water    ..........   20  oz.  oz.    each.     Feed    every    3 

Cane  sugar  ......   y4  oz.  (30  cals.)          hours  at  6,  9,  12  A.M.,  3,  6, 

9  P.M.,  and  2  A.M. 

Total  number  of  calories  230,  or  approximately  23  calories  per  pound. 
Increase  the  milk  and  decrease  the  water  one  ounce  each  day  up  to  15  oz. 
of  milk  and  15  oz.  of  water. 

February  1    (4  days  later)  :     Weight,  9  Ib.   15  oz. 

Gain,  1  oz. 

General  Condition.  —  Excellent. 
Stools.  —  One  soft,  yellow,  normal. 
Vomiting.  —  None. 
Appetite.  —  Hungry. 
Sleep.  —  Good. 

Treatment.  —  Food  prescribed  : 

Milk  ............   15  oz.  )  (300  cals.)      Divide  and  feed  as  before. 

Water    ..........   15  oz.  f  ^^ 

Cane  sugar  ......   %  oz.  (60  cals.  ) 

Total  number  of  calories  360,  or  approximately  36  calories  per  pound. 
February  7    (6  days  later)  :     Weight,  10  Ib.  2  oz. 

Gain,  3  oz. 

General  Condition.  —  Excellent. 
Stools.  —  Normal. 
Vomiting.  —  None. 
Appetite.  —  Still  hungry. 
Sleep.  —  Good. 

Treatment  .  —  Food  prescribed  : 

Milk  ............   18  oz.  )  ...   ,    (360  cals.)      Divide   and   feed   as   before 

Water  ...........   18  oz.  f  b  (5+  oz.  at  each  feeding)  . 

Cane  sugar  ......   %  oz.  (90  cals.) 

Total  number  of  calories  450,  or  44+  calories  per  pound. 

February   11    (4  days  later):     Weight,    10  Ib.   4  oz. 

Gain,  2  oz. 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  83 

General  Condition. — Excellent. 
S  too  Is. — Normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk 20  oz.  |       .         (400  cals.)      Divide  and    feed    as   before 

Water    20  oz.  j  boiled  (5y8  Oz.  at  each  feeding) . 

Cane  sugar 1  oz.  ( 120  cals. ) 

Total  number  of  calories  520,  or  50+  calories  per  pound. 

February  22    (11  days  later):     Weight,   10  Ib.    12  oz. 

Gain,  8  02. 

General  Condition. — Excellent. 
Stools. — Normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

Treatment. — Food  prescribed: 

Milk 20      oz.  )  (400  cals.)      Divide  and  feed  as  before. 

Water    20       oz.  \  **"* 

Cane  sugar   1%  oz.  (180  cals.) 

Total  number  of  calories  580,  or  54-  calories  per  pound. 

INFANTS  WHOSE  PREVIOUS  FOOD  HAS  NOT  CONTAINED  FRESH 

Cow 's  MILK 

An  infant  who  has  previously  been  fed  upon  an  artificial 
food  not  containing  fresh  cow's  milk  should  at  first  be 
started  with  small  quantities  of  milk.  For  a  few  days  or 
weeks,  or  until  the  infant  has  become  accustomed  to  milk 
feedings,  it  is  well  to  boil  this  mixture  of  milk  and  water. 
The  amount  of  sugar  that  is  first  added  to  the  food  should 
depend  upon  the  condition  of  the  infant's  digestive  appara- 
tus, as  well  as  upon  the  quantity  of  sugar  that  the  previous 
food  has  contained.  For  instance,  the  ordinary  brand  of 
condensed  milk  contains  over  50  per  cent,  sugar.  When  an 
infant  has  been  fed  with  condensed  milk  if  this  large  quan- 
tity of  sugar  has  not  already  caused  digestive  disturbances, 
it  is  safe  when  changing  to  a  cow's  milk  formula  to  begin 
feeding  such  an  infant  with  sugar  at  once,  although  it  is 


84  SIMPLIFIED  INFANT  FEEDING 

advisable  to  start  with  less  than  an  ounce.  In  Case  XIII 
it  may  be  seen  that  the  infant  was  started  with  a  fairly  weak 
dilution,  and  that  for  a  few  days  at  least  very  small  quanti- 
ties of  sugar  were  used. 

CASE  XIII 

(Illustrating  the  institution  of  fresh  cow's  milk  feedings  with  a  poorly  nour- 
ished infant  previously  fed  upon  condensed  milk) 

August    12:     Age,    4%    months.    Birth  weight,  9  Ib. 

Present  weight,  11  Ib.  5  oz. 
Gain  since  birth,  2  Ib.  5  oz. 

General  Condition. — Pale,  poorly  nourished,  undersized,  skin  slightly  wrinkled. 
Stools. — One  normal  a  day. 
Vomi  ting. — None. 
Appetite. — Hungry. 
Sleep. — Cries  a  great  deal  during  the  day;  sleeps  fairly  well  at  night,  though 

restless. 

Temperature,  98.6°  F. 
Chief  Complaint. — Insufficient  gain  in  weight. 

Previous  Food. — Breast-fed  the  first  6  weeks  of  life ;  since  then  has  had : 

Condensed  milk 3  teaspoonfuls      Fed    6  oz.  every  2   hours,    10  or    11 

Water 6  oz.  feedings  in  24  hours. 

Treatment. — Food  prescribed : 

Milk 15  oz.  |  (300  cals.)       Divide  into  7  feedings.    Feed 

Water 25  oz.  j  b  6-  oz.  every  3  hours  at  6,  9, 

Cane    sugar y2  oz-  (60  cals.)  12  A.M.,  3,  6,  9  P.M.,  and  2 

A.M. 

Total  number  of  calories  360,  or  32  calories  per  pound.     Caloric  require- 
ments, 55  per  pound. 

August  17    (5  days  later):     Weight,  11  Ib.  6  oz. 

Gain,  1  oz. 

General  Condition. — The  same. 
Stools. — Two  normal  a  day. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Still  cries  a  great  deal  in  the  daytime. 

Treatment. — Food  prescribed : 

Milk 20  oz.  )  ...  ,    (400  cals.)       Divide  into  7  feedings  and 

Water 22  oz.  f  b  feed  as  before   (6  oz.  at 

Cane  sugar %  oz.  (90  cals.)  each  feeding). 

Total  number  of  calories  490,  or  43+  calories  per  pound. 

August  20    (3  days   later):     Weight,  11  Ib.  7  oz. 

Gain.  1  oz. 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  85 

• 

General  Condition. — As  before. 

8 tools. — One  or  two  normal  a  day. 

Vomiting. — None. 

Appetite. — Still  hungry. 

Sleep. — Better,  but  still  cries  a  great  deal. 

Treatment. — Food  prescribed : 

Milk 22  oz.   )  (440  cals.)       Divide  and  feed  as  before. 

Water..' 20  oz.  f  ^ 

Cane  sugar 1  oz.  (120  cals.) 

Total  number  of  calories  560,  or  50-  calories  per  pound. 

August  27    (7  days  later):     Weight,  11  Ib.  12  oz. 

Gain,  5  oz. 

General  Condition. — Improved. 
Stools. — One  or  two  normal  a  day. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Much  better. 

Treatment. — Food  prescribed: 

Milk 22  oz.  )  (440  cals.)    Divide  and   feed  as  before. 

Water     20  oz.  \  boiled 

Cane  sugar iy2  oz.  (180  cals.) 

Total  number  of  calories  620,  or  53-  calories  per  pound. 

This  infant  continued  to  gain  in  weight  and  made  a  normal  progress  as 
the  food  was  increased  in  strength. 

Cane  sugar  was  used  because  the  infant  had  already  become  accustomed 
to  the  cane  sugar  in  the  condensed  milk  and  had  had  no  digestive  disturbances. 
The  milk  was  boiled  for  a  time  because  the  infant  had  never  had  raw  milk  feed- 
ings, and  it  was,  feared  that  unboiled  milk  might  at  first  cause  indigestion. 
The  first  mixture  used  was  a  little  stronger  than  one-third  milk,  because  of  the 
infant's  age  and  its  extreme  need  of  food. 

INFANTS  WHO  HAVE  BEEN  OVEEFED 

It  is  not  unusual  for  an  infant  to  be  overfed  without  giv- 
ing rise  to  digestive  symptoms.  At  the  same  time  the  infant 
may  appear  hungry,  cry  a  great  deal,  and  not  gain  properly 
in  weight.  The  overfeeding  may  be  in  the  form  of  too  great 
a  quantity;  that  is,  the  number  of  calories  may  be  far  in 
excess  of  its  needs.  Again,  there  are  infants  who,  though 
they  are  getting  the  proper  number  of  calories,  are  receiving 
one  element  of  the  food,  such  as  fat  or  sugar,  in  excess. 


86  SIMPLIFIED  INFANT  FEEDING 

* 

Overfed  infants  who  have  not  had  digestive  disturbances 
in  spite  of  their  bad  feeding  are  usually  very  easy  to  control 
when  a  correct  feeding  is  given,  but  it  is  always  necessary 
to  give  (for  a  few  days  at  least)  a  food  which  does*  not 
fulfil  their  caloric  needs. 

CASE  XIV 

(Illustrating  excessive  sugar  feeding  as  well  as  overfeeding  in  the  number 
of  calories) 

November  10:     Age,  4  months.     Birth  weight  unknown. 

Present  weight,  13  Ib. 

General  Condition. — Fat,  large,  normal. 

Stools. — Three  or  four  normal. 

Vomiting. — None. 

Appetite. — Appears  hungry;  takes  all  the  food  offered. 

Sleep. — Cries  most  of  the  day,  sleeps  fairly  well  at  night. 

Temperature,  98.6°  F. 

Chief  Complaint. — Crying  and  colic. 

Previous  Food: 

Milk. 28  oz.  )       t  b  '1  d.  ^56°  cala-)  Fec*  6  °z-  every  2  hours,  10 

Water K .  32  oz.  f  feedings  in  24  hours. 

Milk  sugar  ....    18  teaspoonfuls  (260  cals.) 

Lime  water 3  oz. 

Total  number  of  calories  820,  or  63  calories  per  pound.  The  caloric  needs 
are  50  calories  per  pound,  or  a  total  of  650  calories. 

Treatment. — Food  prescribed : 

Milk   22  oz.  )              .  (440  cals.)       Divide  into  7  feedings.    Feed 

Water  20  oz.  j"  not  bo°ed  6  oz.  every  3  hours,  at  6,  9, 

Cane  sugar   . .   %  oz.  (60  cals.)           12  A.M.,  3,  6,  9  P.M.,  and  2 

A.M. 

Total  number  of  calories  500,  or  39+  calories  per  pound. 

The  total  daily  quantity  is  cut  down  to  42  ounces,  the  su?ar  is  reduced 
to  y2  ounce  on  account  of  the  excessive  amount  in  the  previous  food,  and  only 
39  calories  per  pound  are  given,  in  order  to  give  th?  gastro-intestinal  tract 
less  work  for  a  few  days.  The  milk  was  not  boiled  because  the  previous  food 
being  unboiled  had  not  caused  vomiting  or  bad  stools  in  spite  of  excess  of 
sugar,  frequent  feedings  and  hiirh  caloric  content. 

November  13  (3  days  later)  :     Weight,  13  Ib. 

No  gain  or  loss. 

General  Condition. — Same  as  at  the  last  visit. 
Stools. — One  or  two  normal  a  d»v. 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  87 

Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good;  cries  little. 

*  Treatment.— Food  prescribed : 

Milk    22  oz.  )  .          (440  cals.)  Divide  into  6  feedings.   Feed 

Water    20  oz.  j  n  6  oz.  every  3  hours,  at  6,  9, 

Cane  sugar    . . .  .      1  oz.  ( 120  cals. )      12  A.M.,  3,  6,  9  P.M. 

Total  number  of  calories  560,  or  43  calories  per  pound. 

November  16    (3  days  later)  : Weight,  13  Ib.  2  oz. 

Gain,  2  oz. 

General  Condition. — The  same. 
Stools. — One  constipated. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

Treatment . — Food  prescribed : 

Milk    24      oz.  )  (480  cals.)  Divide   and    feed    as    before 

Water    20      oz.  \  n  (6  +  oz.  at  a  feeding) . 

Cane  sugar  ...     1%  oz.  (180  cals.) 

Total  number  of  calories  660,  or  50-  calories  per  pound. 

November  24  (8  days  later)  :    Weight,  13  Ib.  11  oz. 

Gain,  9  oz. 

General  Condition. — Excellent. 
Stools. — Two  normal  a  day. 
Vomiting. — None. 
Appetite. — Satisfied. 
Sleep. — Good. 

A  continuous  gain  in  weight  took  place  thereafter,  the  food  being  increased 
from  time  to  time  so  that  the  caloric  requirement  might  keep  pace  with  the 
increase  in  weight. 

CASE  XV 

The  following  case  shows  an  infant  without  digestive  disturbances  (except 
for  mild  constipation)  who  had  been  fed  too  concentrated  a  food  from  the 
first  two  months  of  life : 

April  27 :     Age,   Qy3  months.     Birth  weight,  9  Ib.  8  oz. 

Present  weight,  14  Ib.  10  oz. 
Gain  since  birth,  5  Ib.  2  oz. 

General  Condition. — Markedly  rhachitic,  pale,  and  for  the  last  three  days  has 
been  having  convulsions,  three  in  all  during  this  period.  Fairly  well 
nourished. 

Stools. — One  constipated,  with  the  aid  of  milk  of  magnesia. 
Vomiting. — At  the  time  of  convulsions  only. 


88  SIMPLIFIED  INFANT  FEEDING 

Appetite.  —  Appears  hungry;  takes  all  the  food  offered. 

Temperature,  98.6    F. 

Sleep.  —  Poor  ;  cries  a  great  deal. 

Chief  Complaint.  —  Convulsions. 

Previous  Food: 

Milk  .....  .....  28       oz.  )       .          (  560  cals.  )      Fed  7  oz.  every  4  hours,  5 

Water    .......     7       oz.  |  bolled-  feedings  in  24  hours. 

Cane  sugar  ____      1%  oz.  (180  cals.) 

Total  number  of  calories  740,  or  50-  calories  per  pound. 
Treatment.  —  Sodium  bromide,  4  grs.  ;  chloral  hydrate,  1  gr.,  every  6  hours. 

Food  prescribed: 
Milk  ............   21  oz.   (420  cals.)       Divide  into  6  feedings.     Feed  7  oz.  at 

Water    ..........   21  oz.  6,  9,  12  A.M.,  3,  6,  9  P.M. 

Dextri-maltose  ...    yz  oz.     (60  cals.) 

Total  number  of  calories  480,  or  32  calories  per  pound. 
May  4  (7  days  later):     Weight,    14  Ib.   8  oz. 

Loss,  2  oz. 

General  Condition.  —  Brighter  than  at  last  visit  ;  no  convulsions. 
Stools.  —  One  a  day  with  enema. 
Vomiting.  —  None. 
Appetite.  —  Hungry. 
.—  Better. 


Treatment.  —  Food  prescribed  : 

Milk  ......  ......   24  oz.  )  (480  cals.)       Divide  and  feed  as  before  (8 

Water  ...........   24  oz.  [  b  oz.  at  a  feeding)  . 

Dextri-maltose  ...      1  oz.  (120  cals.) 

Total  number  of  calories  600,  or  41+  calories  per  pound. 
May  11  (7  day  s  later):     Weight,   14  Ib.   11  oz. 

Gain,  3    o/. 

General  Condition.  —  Improved;  no  convulsions 
Stools.  —  Two  normal  a  day. 
Vomiting.  —  None. 
Appetite.  —  Hungry. 
Sleep.  —  Good. 

Treatment.  —  Food  prescribed: 

Milk   ...........  28      oz.  )  (560  cals.)    Divide  and  feed  as  before. 

Water  ..........   20      oz.  [  D0"6*1- 

Dextri-maltose    ..      ly2  oz.  (180  cals.) 

Total  number  of  calories  740,  or  approximately  50  calories  per  pound. 
May  18  (7  days  later)  :     Weight,    15    Ib.    5   oz. 
Gain,  10  oz. 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  89 

General  Condition. — Improving;  no  convulsions. 
Stools. — Two  normal  a  day. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

INFANTS  WHO  HAVE  BEEN  UNDERFED 

Overfeeding  in  the  form  of  too  much  food  or  too  strong 
food  or  too  frequent  feedings  is  an  error  that  is  commonly 
made  by  the  laity,  while  the  physician  is  more  apt  to  err  by 
underfeeding.  The  physician,  with  a  profound  respect  for 
the  digestive  disturbances  that  may  already  exist,  and  fear- 
ful of  causing  more,  is  apt  to  delay  too  long  in  increasing 
the  strength  of  the  feeding. 

The  following  case  seen  in  consultation  is  an  exaggerated 
example  of  underfeeding.  The  infants  (twins)  were  vomit- 
ing slightly.  At  this  time  they  were  receiving  only  eighteen 
calories  per  pound  in  twenty-four  hours,  most  of  this  being 
in  the  form  of  sugar.  It  was  not  possible  for  them  to  gain 
in  weight,  and  the  wonder  is  that  they  did  not  starve  to  death, 
considering  that  their  caloric  needs  were  sixty-five  calories 
per  pound,  since  they  were  emaciated  babies.  ( See  page  58. ) 

CASE  XVI 
(An  exaggerated  case  of  underfeeding) 

May  7  (twins)  :     Age,  1  month.     Birth  weight   (boy),  4  Ib.  4  oz. 

Present  weight,  4  Ib. 
Loss  since  birth,  4  oz. 
Birth  weight  (girl),  5  Ib.  4  oz. 
Present  weight,  4  Ib.  8  oz. 
Loss  since  birth,  12  oz. 

General   Condition. — Emaciated,   small,   weak,   feeble  cry,    fontanel   and   eyes 

sunken,  skin  wrinkled,  pale. 

Stools. — Small,  watery,  erreen  stool  with  the  aid  of  milk  of  magnesia  each  day. 
Vomiting. — A  little  after  each  feeding. 
Appetite. — Take  all  the  food. 
Sleep. — Good. 
Chief  Complaint. — Loss  in  weight. 


90 

Previous  Food.  —  Breast  milk  had  been  given  without  success  for  one  week  only. 

For  the  next  two  weeks  they  had  had: 
Whole  milk  .......     1  oz.   (20  cals.)       Fed  2  oz.  every  2  hours,  10  feedings 

Lime  water  .......      1  oz.  in  24  hours. 

Water    ...........    18  oz. 

Dextri-maltosc  ----   %  oz.   (60  cals.) 

Total  number  of  calories  80,  or  18  to  20  per  pound.     Caloric  needs,  65 
calories  per  pound. 

Treatment.  —  Food  prescribed  for  each  infant: 

7  oz.          .          (140  cals.)      Divide  into  10  feedings.  Feed 


Milk  ............     7  oz.  |       .          (140  cals.)      Divide  into  10  feedings.  Feed 

Water    ..........   14  oz.  [  boiled'  2  oz.  at  6,  8,  10,  12  A.M.,  2, 

Dextri-raaltose  ..  .   %  oz.  (30  cals.)  4,  6,  8,  10  P.M.,  and  2  A.M. 

Increase  the  milk  one  ounce  every  other  day,  allowing  the  amount  of  water 
to  remain  constant  until  the  formula  is  half  milk  and  half  water.  If  there  is 
BO  indigestion,  gradually  increase  the  sugar  up  to  three-quarters  of  an  ounce 
in  twenty-four  hours.  At  the  end  of  two  weeks  the  food  will  be: 

Milk  .......    .   14  oz.  )       .  (280  cals.)        Divide  and  feed  as  before  (3 

Water  .......    14  oz.  J  bolle<L  oz.  at  a  feeding). 

Dextri-maltose.  %  oz.  (90  cals.) 

Total  number  of  calories  370,  or  65  calories  per  pound  (allowing  for  a  gain 
in  weight  during  two  weeks). 

Frequent  reports  from  the  physician  in  charf  e  showed  a  progressive  gain  in 
weight  on  this  diet  (the  weight  being  doubled  in  less  than  three  months) 
and  a  cessation  of  the  vomiting.  Later  the  food  was  increased  to  correspond 
with  the  increase  in  weight. 

The  next  case  is  also  one  of  underfeeding,  but  in  a  lesser 
degree.  This  infant  was  receiving  410  calories,  or  about 
37  calories  per  pound,  which  is  not  extreme  underfeeding, 
since  the  caloric  needs  were  50  to  55  calories  per  pound. 
Nevertheless,  the  food  was  deficient,  and  a  gradual  increase 
in  the  number  of  calories  and  a  substitution  of  whole  milk 
for  the  top  milk  used  were  needed. 

CASE  XVII 
(Illustrating  a  moderate  case  of  underfeeding) 

April   17:     Age,  3y2  months.     Birth  weight,  9  Ib.  4  oz. 

Present  weight,  10  Ib.  14  oz. 
Gain  since  birth,  1  Ib.  10  oz. 


WHEN  TO  IGNORE  CALORIC  REQUIREMENTS  91 

General    Condition. — Fairly    well    nourished,    undersized,    pale,    strong,    and 

vigorous. 

Stools. — Constipated;  one  or  two  a  day  with  the  aid  of  magnesia. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 
Chief  Complaint. — Constipation,  tendency  to  poor  nourishment. 

Previous  Food. — Breast-fed  for  three  weeks  without  satisfactory  gain  in 
weight;  was  then  put  upon  Eskay's  Food  and  milk  mixture.  Two  weeks 
ago,  because  of  lack  of  gain  in  weight,  the  following  mixture  was  given  by 
the  physician  in  charge: 

Top  milk  (8  per  cent,  fat)  . .    12  oz.   (360  cals.)       Fed  4%  oz.  every  2  Ms  hours, 

Water 26  oz.  8  feedings  in  24  hours. 

Lime  water   2  oz. 

Milk  sugar 2  tablespoonfuls 

(50  cals.) 

Total  number  of  calories  410,  or  37  per  pound.  Caloric  needs,  550  calories, 
or  55  calories  per  pound. 

Treatment. — Food  prescribed : 

Milk 15  oz.  |  (300  cals.)       Divide  into  7  feedings.    Feed 

Water    20  oz.  J  boiled  5  Oz.  at  6,  9,  12  A.M.,  3,  6,  9 

Dextri-maltose  ...   y2  oz.  ( 60  cals. )  P.M.,  and  2  A.M. 

360  calories,  or  38  calories  per  pound. 

Increase  the  milk  one  ounce  each  day  up  to  half  milk  and  half  water, 
always  allowing  the  water  to  remain  stationary.  With  the  increase  of  milk 
each  day  the  quantity  at  a  feeding  will,  therefore,  be  increased.  At  the  end 
of  five  days  the  food  will  be: 

Milk    20  oz.  )  (400  cals. ) 

Water     20  oz.  J"  boiled 

Dextri-maltose    . .   %  oz.  (60  cala ) 

460  calories,  or  42  calories  per  pound. 

The  infant  is  still  underfed,  but  it  is  well  to  increase  the  food 
slowly  in  this  way,  especially  since  the  sugar  was  changed  from  milk  sugar 
to  malt  sugar. 

April   28    (11    days   later):     Weight,  11  Ib.  1  oz. 

Gain,  3  oz. 

General  Condition. — As  before. 
Stools. — One  hard  with  the  aid  of  milk  of  magnesia. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 


!L>  SIMPLIFIED  INFANT  FEEDING 

Treatment. — Food  prescribed: 

Milk 20  oz.  }  (400  cals,)  Divide  into  7  feedings.   Feed  6- 

Water    20  oz.  i"  "Olle<1-  oz.  every  3  hours  as  before. 

Dextri-maltose  . . :   %  oz. 

(In  3  days) 1  oz.  (120  cals,) 

520  calories,  or  47  calories  per  pound. 

May  3  (5  days  later):     Weight,   11     Ib.   4  oz. 
Gain,    3  oz. 

General  Condition. — As  before. 
Stools. — Normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk    22  oz.    )  (440  cals.)  Divide  and  feed  as  before. 

Water  20  oz.   j^H 

Dextri-maltose    ...    iy2  oz.  (180  cals.) 

620  calories,  or  55  calories  per  pound. 

May    10    (7   days   later):     Weight,  11  Ib.  12  oz. 

Gain,  8  oz. 

General  Condition. — Good. 
Stools. — One  or  two  normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

This  infant  continued  to  do  well,  the  food  being  strengthened  as   the 
weight  increased  and  the  calories  kept  at  about  50  to  55  per  pound. 


CHAPTER  VII 


THE  STOOLS 

A  MOTHER'S  or  nurse's  description  of  the  stools  should 
never  "be  accepted  unreservedly,  but  an  inspection  of  them 
should  be  made  at  each  visit.    The  following  facts  should 
be  ascertained  in  every  case  of  diarrhoea: 
1.  Duration   of   the   diar-       7.  Reaction. 

8.  Presence  of  mucus. 

9.  Presence  of  curds. 

10.  Presence  of  blood. 

11.  Whether  cathartics 


have   been     adminis- 
tered or  not. 


rhoea. 

2.  Number  of  stools  in  24 

hours. 

3.  Size. 

4.  Color. 

5.  Consistency. 

6.  Odor. 

Duration. — A  diarrhoea  that  has  lasted  a  long  time  is  apt 
to  be  more  difficult  to  overcome.  When  the  bowels  have 
reached  a  chronic  state  of  irritation,  the  treatment  must  be 
influenced  by  this  fact,  and  the  prognosis  is  not  as  favor- 
able. A  diarrhoea  of  short  duration,  if  caused  by  intestinal 
indigestion,  is  quickly  amenable  to  proper  treatment.  This, 
however,  is  not  true  of  acute  infectious  diarrhoea. 

The  Number  of  the  Stools. — The  normal  number  of  stools 
varies.  One  a  day  is  sufficient,  although  it  is  sometimes  hard 
to  convince  a  mother  that  this  is  true.  Generally  more  than 
three  or  four  may  be  considered  pathological.  The  impor- 
tance of  the  frequency  of  the  stools  has  been  much  exag- 
gerated. An  infant  may  have  marked  intestinal  indigestion 
with  only  three  or  four  stools  a  day,  and,  on  the  other  hand, 
there  may  be  three  or  four  perfectly  normal  stools  which 
show  no  indigestion  whatever.  Some  infants  have  three  or 
more  stools  a  day  habitually  all  through  the  bottle  period 
and  thrive  and  gain  in  weight  just  the  same  as  an  infant  who 

93 


94  SIMPLIFIED  INFANT  FEEDING 

has  only  one.  When  an  infant  whose  habit  it  is  to  have  one 
stool  a  day  suddenly  begins  to  have  three  or  four,  especially 
if  their  consistency  is  looser,  or  if  they  show  other  signs  of 
indigestion,  it  should  be  looked  upon  as  a  warning  that  diar- 
rhoea is  imminent.  When  the  stools  are  very  numerous 
(ten  to  twenty  or  even  more  in  twenty-four  hours)  it  is  most 
likely  to  be  an  indication  of  a  severe  type  of  diarrhoea. 
Frequent  stools  are  also  caused  by  an  involvement  of  the 
colon,  which  has  become  so  irritable  that  it  will  not  retain 
the  fecal  matter  as  it  comes  from  the  upper  bowel,  even  when 
the  small  intestines  are  doing  their  work  well.  The  stools 
may  be  numerous,  too,  in  an  infant  who  is  underfed,  but 
they  are  always  small  in  this  case. 

Size  of  the  Stools. — The  size  of  the  stool  may  give  a  good 
deal  of  information  when  considered  in  conjunction  with 
the  number.  The  normal  size  of  the  stools  is  hard  to  esti- 
mate, since  it  depends  almost  entirely  upon  the  food  which 
the  infant  is  taking.  The  infant  fed  on  strong  whole-milk 
mixtures  which  leave  a  great  deal  of  residue  will  have  a  very 
large  stool.  An  infant  that  is  very  much  underfed  may  have 
only  a  slight  staining  of  the  diaper,  although  this  may  occur 
many  times  a  day.  Infants  fed  on  malted  milk  or  some  of 
the  proprietary  foods  which  are  given  without  cow's  milk 
will  also  have  small  stools. 

Color. — The  color  of  the  normal  stool  depends  upon  the 
food  that  is  being  taken.  It  is  often  possible  to  tell  what  food 
an  infant  is  getting  by  examining  the  stools.  An  infant 
receiving  barley  or  other  cereals,  or  starches,  will  have  a 
brown  stool,  and  this  will  often  be  a  very  dark  brown  if  the 
diet  is  entirely  starch.  Whole-milk  mixtures  will  give  stools 
of  a  very  pale  yellow  color,  often  shading  into  a  pale  green, 
especially  in  an  infant  who  has  previously  had  a  diarrhoea. 
This  pale  green  color  is  considered  normal  with  strong  milk 
mixtures,  provided  there  are  no  other  abnormalities,  such 
as  curds  and  mucus,  in  the  stool. 


THE  STOOLS  95 

Although  the  color  of  the  stool  is  not  as  significant  as 
many  of  the  other  points  of  consideration,  it  figures  largely 
in  most  descriptions  of  them.  The  first  thing  that  the 
mother  observes  is  that  her  baby's  stools  are  " green." 
Many  hospital  records  show  a  " green  stool"  recorded  with- 
out further  description.  This  is  unfortunate,  since  a  stool 
may  be  green  yet  firm,  smooth,  and  normal  in  every  other 
respect.  A  stool  which  has  turned  green  after  standing  for 
some  time  is  not  pathological.  An  infant  who  has  recently 
had  an  intestinal  disturbance  will  very  often  have  stools 
which  are  yellow  when  evacuated,  but  which,  after  remaining 
exposed  to  the  air  for  a  short  time,  turn  green.  In  severe 
diarrhoea  the  green  color  is  an  indication  that  the  food  has 
passed  rapidly  through  the  bowels  and  that  the  bile  has  not 
had  a  chance  to  undergo  a  complete  change,  as  it  does  when 
the  intestinal  digestion  is  normal. 

Consistency. — The  normal  consistency  of  the  stool  also 
depends  upon  the  food  that  is  given.  The  proper  consistency 
of  the  stool  in  an  infant  that  is  artificially  fed  should  be 
about  that  of  a  good,  stiff  ointment,  and  should  be  of 
sufficient  firmness  to  retain  the  round  shape  in  which  it  comes 
from  the  rectum.  The  normal  stool  of  a  bottle-fed  infant 
should  also  be  homogeneous, — that  is,  smooth  and  all  of  the 
same  quality.  When  pressed  out  in  the  diaper  it  should 
be  smooth  and  glistening,  as  a  good  ointment  or  paste 
would  be. 

Frequently  a  stool  is  moistened  with  urine,  and  a  normal 
stool  in  this  state  may  appear  to  be  loose.  A  stool  which 
was  watery  when  freshly  passed  sometimes  appears  dry 
because  the  watery  elements  of  the  stool  have  been  absorbed 
by  the  diaper.  The  loose,  watery  stool  derives  its  moisture 
from  the  fluid  taken  with  the  food  or  from  an  abnormal 
amount  of  intestinal  secretion.  Usually  the  looser  the  stool 
the  more  severe  is  the  diarrhoea,  other  things  being  equal. 
The  loose  stool  may  also  be  foamy,  but  unless  seen  when 


96  SIMPLIFIED  INFANT  FEEDING 

freshly  passed  this  characteristic  will  not  be  observed.  The 
foamy  condition  is  probably  due  to  fermentation  of  the 
carbohydrates.  Following  a  diarrhoea,  the  hard,  dry,  or 
even  crumbly  stool  of  constipation  has  no  particular  signifi- 
cance, since  constipation  is  always  welcome  after  diarrhoea. 

Odor. — A  sour  odor  is  due  to  fermentation  of  the  carbo- 
hydrates within  the  intestinal  canal.  This  does  not  neces- 
sarily mean  that  sugar  is  being  given  in  too  great  excess, 
nor  that  it  is  the  entire  cause  of  the  diarrhoea.  The  fat  may 
be  the  original  cause  of  the  indigestion  and  the  sugar  fer- 
mentation a  later  development.  On  the  other  hand,  sour- 
smelling  stools  are  not  an  invariable  accompaniment  of 
fermentative  diarrhoea,  A  foul,  putrefactive  odor  like  that 
of  decayed  meat  indicates  a  putrefactive  diarrhoea. 

Reaction. — The  reaction  of  a  stool  is  of  very  little  impor- 
tance except  in  cases  of  diarrhoea  or  in  infants  who  have 
recently  recovered  from  diarrhoea. 

In  getting  the  reaction,  a  fresh  stool,  uncontaminated  by 
urine,  must  be  used.  If  a  stool  has  been  moistened  by  urine, 
the  reaction  of  the  urine  rather  than  that  of  the  stool  will 
be  the  only  information  obtained. 

As  it  is  often  difficult  for  the  physician  to  see  a  stool 
just  as  soon  as  it  is  passed,  he  must  use  either  a  catheter, 
suppository,  or  a  glass  tube  with  a  hole  blown  in  the  side, 
inserted  in  the  rectum. 

The  reaction  is  alkaline  if  putrefaction  predominates  and 
acid  if  there  is  fermentation  or  a  fatty  acid  formation. 

Curds. — Curds  do  not  appear  in  the  normal  stool.  There 
has  been  much  discussion  concerning  the  cause  and  make-up 
of  curds,  but,  since  this  work  deals  only  with  the  clinical 
aspects  of  feeding,  it  is  not  necessary  to  discuss  the  matter 
here.  It  is  sufficient  to  say  that  the  large,  hard,  bean-like 
masses,  very  tough  and  stringy,  are  never  seen  in  the  stools 
of  an  infant  fed  with  a  boiled  milk  mixture.  When  the  simple 


THE  STOOLS  97 

feedings  advised  in  this  book  are  used  it  is  not  necessary 
to  distinguish  between  curds  due  to  proteid,  fat,  or  sugar 
indigestion,  because  they  can  be  made  to  disappear  by  the 
simple  expedient  of  boiling  the  milk. 

It  is  more  difficult  to  distinguish  between  the-  soft  curds 
of  unboiled  milk  and  the  normal  fecal  masses  which  are  sur- 
rounded and  separated  by  mucus  and  closely  resemble  curds. 
These  two  varieties  may  best  be  distinguished  by  the  fact 
that  the  soft  curds  are  white  on  the  inside  and  often  green 
on  the  outside,  while  the  normal  fecal  masses  are  yellow  in 
color  all  through.  The  fecal  masses,  when  mashed,  appear 
perfectly  smooth  and  homogeneous,  while  soft  curds  are 
more  apt  to  be  stringy. 

Normal  fecal  masses  having  the  appearance  of  curds  are 
of  good  import  rather  than  bad.  These  masses  will  appear 
in  the  stools  of  an  infant  who  has  had  a  severe  diarrhoea, 
within  twenty-four  hours  after  being  put  upon  a  boiled  milk 
and  water  mixture.  The  mother  or  nurse  should  be  warned 
that  this  will  occur  and  that  it  is  desirable,  lest  she  fear  that 
the  milk  is  not  being  digested  and  possibly  discontinue  the 
feeding  of  her  own  accord.  Each  succeeding  stool  will  show 
more  of  the  fecal  masses  and  less  mucus  until,  on  the  third 
or  fourth  day,  the  mucus  will  have  disappeared  and  the  soft, 
homogeneous  stool  will  be  made  up  of  one  large  fecal  mass. 

Mucus. — An  appreciable  amount  of  mucus  is  never  seen 
in  the  normal  stool.  It  can  be  recognized  by  its  glistening 
appearance,  although  it  is  often  simulated  by  undigested 
gruels  appearing  in  the  stool.  An  infant  fed  on  pure  barley 
gruel  may  have  a  watery,  shiny  stool  which  really  contains 
very  little  mucus,  due  to  the  gruel  passing  through  the  bowel 
undigested. 

The  presence  of  mucus  indicates  an  inflammatory  con- 
dition of  the  bowel  or  intestinal  indigestion,  so  it  is  ex- 
tremely important  to  recognize  it.  Other  things  being  equal, 
7 


98  SIMPLIFIED  INFANT  FEEDING 

the  more  mucus  the  more  serious  is  the  diarrhoea.  Often  the 
stool  consists  of  bile-stained  mucus  only,  especially  when  an 
infant  is  on  a  starvation  diet  and  has  been  given  a  cathartic 
which  has  further  irritated  the  bowels.  It  is  not  sufficiently 
recognized  that  underfeeding  will  give  rise  to  these  small, 
thin,  and  often  numerous  mucous  stools.  Generally  all  that 
is  necessary  to  stop  them  is  to  give  a  food  containing  more 
milk,  which  increases  the  bulk  of  the  faeces  and  at  the  same 
time  supplies  sufficient  nourishment 

Mucus  may  be  mixed  through  the  stool  so  that  the  whole 
stool  appears  shiny  and  glistening,  or  it  may  be  entirely 
separated  from  normal  fecal  masses,  curds,  or  other  undi- 
gested matter.  If  it  is  thoroughly  mixed  with  the  faeces  it  is 
an  indication  that  the  irritation  comes  from  high  up  in  the 
bowel,  probably  the  small  intestines,  although  there  may  be 
inflammation  in  the  lower  bowel  also.  Mucus  which  is  sepa- 
rated from  the  curds  or  normal  fecal  matter  comes  from  the 
lower  bowel.  This  mucus  is  a  wise  provision  of  nature, 
furnished  probably  as  a  protection  to  the  intestinal  mucosa, 
and  it  therefore  should  not  be  removed  by  irrigations  or 
cathartics. 

Blood. — When  blood  is  present  in  the  stools  in  any  appre- 
ciable quantity,  provided  it  does  not  come  from  the  rectum 
or  anus,  it  is  of  serious  import.  When  mixed  with  mucus 
and  associated  with  frequent  loose  stools  it  is  indicative  of 
an  infectious  diarrhoea,  usually  dysentery  or  some  organic 
lesion  of  the  intestines. 

A  streak  of  blood  on  the  outside  of  a  hard  stool,  or  pure, 
fresh  blood  associated  with  a  normal  stool,  is  indicative  of 
a  fissure,  ulcer,  polypus,  or  hemorrhoid  in  the  anus  or 
rectum.  Blood  may  also  be  due  to  organic  and  constitutional 
diseases,  such  as  ulcer,  intussusception,  tuberculosis,  scurvy, 
haemophilia,  or  purpura. 

Cathartics. — The  discussion  of  cathartics  will  be  taken  up 
more  thoroughly  elsewhere,  but  it  is  well  to  remember  that 


THE  STOOLS 


99 


many  mothers  habitually  give  cathartics  to  their  infants. 
This  is  true  not  only  in  constipation,  but  in  diarrhoea.  An 
infant  having  a  diarrhoea  should  never  receive  repeated 
doses  of  cathartics.  The  whole  cause  of  diarrhoea  may  be 
the  cathartics  which  a  mother  is  giving  the  infant  each  day 
and  to  which  she  has  become  so  accustomed  that  it  does  not 
even  occur  to  her  to  mention  it.  Careful  inquiry  should  be 
made  in  every  case  to  eliminate  this  possibility. 


CHAPTER  VIII 

THE  CLASSIFICATION  AND  DIAGNOSIS  OF  DIAR- 
RHOEAS IN  BOTTLE-FED  INFANTS 

DIARRHOEA  is  an  abnormal  condition  of  the  bowels  accom- 
panied by  frequent  evacuations.  The  term  is  used  to  cover 
all  conditions  attended  by  frequent  loose  stools. 

There  has  been  no  satisfactory  classification  of  diar- 
rheas. In  a  general  way  there  have  been  two  schools,  one 
composed  of  those  who  consider  that  all  diarrhoeas  are  due 
to  bacterial  infection,  and  the  other  comprised  of  those  who 
consider  that  all  diarrhoeas  are  chemical,  due  to  the  direct 
action  of  the  sugar,  salts,  or  fat  upon  the  digestive  apparatus 
and  upon  metabolism.  It  is  evident  that  neither  school  is 
all  in  the  wrong,  nor  is  either  school  all  in  the  right.  The 
classification  which  is  adopted  in  this  book  and  which  is 
given  below  is  one  which  embraces  both  teachings. 

CLASSIFICATION  OF  DIARRHOEAS  IN  BOTTLE-FED  INFANTS 

INTESTINAL  INDIGESTION 
(Dyspepsia,  Lowered  Tolerance  for  Food) 

(fat 

1.  Simple  intestinal  indigestion  from  <  su£a 

)  proteid 

I  starch 

2.  Underfeeding,  accompanied  by  intestinal  indigestion. 

3.  Overfeeding,  accompanied  by  intestinal  indigestion. 

4.  Recurrent  diarrhoea  due  to  lowered  tolerance  that 

cannot  be  raised  by  the  usual  methods  above  a 
point  where  a  proper  and  continuous  gain  in  weight 
may  be  made. 
100 


DIARRHCEAS  IN  BOTTLE-FED  INFANTS       101 


INFECTIOUS  DIARRHOEA 

1.  Fermentative  diarrhoea  (dyspepsia,  sugar  or  starch 

diarrhoea,  sugar  intoxication) . 

2.  Putrefactive  diarrhoea  (proteid  diarrhoea). 

3.  Mild  types  of  infectious  diarrhoea. 

4.  Dysentery  (acute  infectious  diarrhoea,  ileocolitis,  in- 

toxication). 

5.  Cholera  infantum. 

MISCELLANEOUS 

1.  Sugar  intoxication. 

2.  Mechanical  diarrhoea. 

3.  Diarrhoea  from  cathartics. 

4.  Marasmus  (lost  power  of  assimilation,  decomposition, 

atrophy). 

5.  Other  organic  causes    (typhoid,  amoebic  dysentery, 

tuberculosis,  ulcer,  intussusception). 

Diarrhoeas  may  be  divided  into  three  classes :  intestinal 
indigestion,  infectious  diarrhoea,  and  miscellaneous.  Intes- 
tinal indigestion  is  the  etiological  factor  in  the  largest  class 
of  diarrhoeas.  Infectious  diarrhoeas  are  most  often  seen  in 
the  summer  or  in  warm  weather.  The  two  may  overlap, 
since  an  infant  with  any  form  of  indigestion  is  more  sus- 
ceptible to  an  infection  and  is  consequently  more  liable  to 
an  infectious  diarrhoea. 

The  subdivisions  under  intestinal  indigestion  are  made 
upon  the  basis  of  the  previous  foods  administered.  This  is 
open  to  the  objection  that  it  does  not  seem  to  be  a  scientific 
classification.  It  is  one,  however,  that  is  easily  grasped  by 
the  general  practitioner  and  by  those  who  have  not  been 
able  to  follow  the  feeding  literature  in  its  devious  paths. 
This  classification  is  also  the  most  useful  one  from  the  stand- 
point of  treatment.  The  subdivisions  have  a  scientific  basis, 
too,  if  properly  interpreted. 

All  of  the  classes  of  intestinal  indigestion  and  the  milder 
forms  of  fermentative  diarrhoea  would  be  called  dyspepsia 


102  SIMPLIFIED  INFANT  FEEDING 

by  the  Finkelstein  school.  Severe  forms  of  sugar  indiges- 
tion, as  well  as  some  of  the  forms  of  severe  infectious  diar- 
rhoea, would  be  classified  as  intoxication.  "Intestinal  indi- 
gestion" seems  to  the  author  a  better  term  to  use  than 
Finkelstein 's  word  "  dyspepsia, "  because  in  this  country  the 
latter  term  is  used  loosely  by  the  laity  to  designate  all  forms 
of  gastric  indigestion. 

Simple  intestinal  indigestion  is  caused  by  feeding  mix- 
tures containing  more  fat,  sugar,  proteid,  or  starch  than 
the  individual  infant  is  capable  of  digesting,  or  by  feeding 
these  elements  in  a  form  that  cannot  be  digested  by  the 
infant.  Most  infants  with  diarrhoea  due  to  intestinal  indi- 
gestion have  a  combination  of  fat,  sugar,  and  proteid  indi- 
gestion which  perhaps  was  originally  due  to  one  of  these 
elements-  only.  For  instance,  a  diarrhoea  which  was  orig- 
inally caused  by  fat  may  have  so  lowered  the  digestive  capac- 
ity of  the  intestines  that  the  power  to  digest  fat,  sugar, 
proteid,  or  starch  is  decreased.  Often  it  is  not  possible 
to  differentiate  between  fat,  sugar,  proteid,  or  starch  diar- 
rhoea, nor  is  it  necessary  from  the  very  practical  stand-point 
of  treatment,  for,  by  omitting  the  starch  and  artificial  sugar 
altogether,  boiling  the  milk  to  make  the  proteid  more  diges- 
tible and  cutting  the  fat  down  to  the  amount  contained  in 
about  one- third  milk  and  two-thirds  water  (fat-free  milk  in 
the  more  severe  types),  the  diarrhoea  may  be  overcome. 

Indigestion  caused  by  fat  is  usually  due  to  the  use  of  top 
milks  or  cream.  These  feedings  do  not  necessarily  cause 
indigestion  in  all  infants.  They  may  be  easily  digested  by 
infants  having  a  good  digestive  capacity  or  by  those  whose 
digestive  power  has  not  been  lowered  or  overtaxed  by  such 
mixtures.  Fat  indigestion  is  seldom  so  severe  that  an  in- 
fant cannot  take  all  the  fat  contained  in  whole  milk  (mixed 
milk),  diluted  three  or  four  times,  provided  no  artificial 
sugar  is  added  to  it,  although  it  is  occasionally  necessary 
to  use  skimmed  milk  mixtures  in  extreme  cases. 


DIARRHCEAS  IN  BOTTLE-FED  INFANTS       103 

Sugar  indigestion  is  caused  by  giving  an  excess  of  sugar. 
Some  infants  have  a  very  low  capacity  for  digesting  sugar, 
often  due  to  the  error  of  giving  too  much  of  it  at  some  time 
in  the  past.  Occasionally  too  much  sugar  is  given  at  the 
beginning  of  artificial  feeding,  or  the  sugar  is  later  increased 
beyond  the  normal  capacity  of  the  infant.  iSugar  is  fre- 
quently given  too  soon  or  increased  too  rapidly  after  an 
attack  of  diarrhoea,  The  increase  in  an  infant's  tolerance 
for  sugar  is  very  gradual,  and  consequently  the  sugar  must 
be  increased  gradually. 

Gruels  are  undoubtedly  a  contributing  factor  in  the  cause 
of  diarrhoea  in  very  young  infants  when  given  in  milk  and 
sugar  mixtures.  For  this  reason,  and  also  to  simplify  the 
treatment  of  diarrhoea  by  eliminating  this  possibility,  it  is 
best  not  to  use  gruels  as  diluents  in  feeding  these  infants. 


Since  it  is  not  necessary,  as  was  formerly  thought,  to  use 
gruels  to  make  the  curds  more  digestible,  nothing  is  gained 
by  giving  them,  and  one  possible  source  of  indigestion  is 
eliminated. 

The  word  tolerance  seems  a  very  good  term  to  use  as  an 
expression  of  an  infant's  ability  to  digest  and  assimilate 
food.  Indigestion,  whether  from  sugar  or  fat,  lowers  the 
infant's  tolerance  for  any  food.  Feeding  weak  dilutions  of 
milk  without  sugar  gives  the  gastro-intestinal  tract  a  chance 
to  recuperate  from  the  fat  and  sugar  indigestion  and  thus 
raises  the  tolerance  so  that  the  milk  can  gradually  be  made 
stronger,  increased  in  quantity,  and  later  sugar  is  cautiously 
added.  While  these  increases  are  being  made  in  the  food 
the  tolerance  is  increasing.  Practically  all  cases  of  simple 
indigestion  due  to  fat,  sugar,  or  starch  are  amenable  to  this 
treatment  (which  is  the  reason  that  it'  is  not  deemed  neces- 
sary to  classify  them  separately) . 

Underfeeding  includes  all  those  cases  that  are  fed  such 
weak  mixtures  or  so  little  food  that  they  could  not  gain  even 
if  they  did  not  have  intestinal  indigestion.  Unfortunately, 


104  SIMPLIFIED  INFANT  FEEDING 

many  of  these  infants  have  a  more  or  less  severe  grade  of  in- 
testinal indigestion  and  diarrho3a,  and  their  tolerance  has 
been  gradually  reduced  throughout  the  time  the  indigestion 
has  lasted.  They  are  therefore  a  difficult  class  of  cases  to 
treat. 

Underfeeding  is  usually  brought  about  in  the  following 
i.    J^manner :  An  infant  having  a  diarrhoea  due  to  intestinal  indi- 
gestion is  wrongly  treated  by  weakening  the  food, — that  isr 


giving  a  mixture  containing  less  fat,  a  little  less  sugar, 
and  less  proteid.  This  does  not  stop  the  diarrhoea,  so  the 
food  value  is  again  reduced.  The  weaker  food  is  still  undi- 
gested, and  the  process  of  weakening  is  repeated  until  the 
infant  is  getting  not  nearly  enough  food  to  sustain  it.  In 
the  same  way  an  infant  is  wrongly  given  plain  barley  gruel 
to  stop  a  fermentative  diarrhoea.  The  stools,  of  course, 
do  not  improve,  and  the  plain  gruel  is  continued  sometimes 
for  two  or  three  weeks,  because  it  is  reasoned  that  if  the 
infant  cannot  digest  so  simple  a  food  as  gruel  it  would 
certainly  not  be  able  to  digest  milk.  Diarrhoea  in  such  cases 
is  due  to  starvation.  Possibly  the  fact  that  the  gruel  does 
not  leave  enough  residue  in  the  intestinal  canal  to  enable 
the  intestines  to  functionate  properly  also  enters  into  the 
cause.  Malted  milk  and  some  of  the  proprietary  foods  which 
are  given  without  milk  often  act  in  the  same  way,  and,  in 
addition,  the  diarrhoea  may  also  be  fermentative  in  type 
on  account  of  the  high  carbohydrate  content  of  the  food. 
Milk  and  water  boiled  together  without  sugar  will  correct 
the  disturbance. 

Overfeeding  is  easier  to  treat,  particularly  if  it  occur  in 
a  well-nourished  infant.  When  occurring  in  poorly-nour- 
ished infants,  the  ease  with  which  the  disease  is  remedied 
will  depend  upon  the  severity  of  the  diarrhoea.  This  sub- 
division needs  little  explanation.  It  is  a  frequent  occurrence 
to  be  called  to  see  infants  that  are  being  fed  much  more  food 
than  they  need  and  which,  if  reckoned  in  calories,  would  be 


DIARRHCEAS  IN  BOTTLE-FED  INFANTS       105 

found  to  be  many  times  the  amount  of  food  they  actually 
require.  There  is  the  constant  inclination  to  increase  the 
food  beyond  an  infant's  needs  in  the  enthusiasm  to  make  a 
big  gain  in  weight.  This  may  bring  about  diarrhoea  with 
stools  showing  various  degrees  of  intestinal  indigestion. 

Lowered  tolerance  that  cannot  be  raised  by  the  usual 
methods  above  the  point  where  the  infant  will  make  a  gain 
in  weight,  needs  further  explanation.  Some  infants  have  a 
very  narrow  limit  between  their  digestive  capacity  and  the 
amount  of  food  they  need  to  make  a  gain  in  weight.  The 
indigestion  can  be  overcome  by  stopping  the  sugar  and  giv- 
ing boiled  milk  and  water  mixtures,  but  when  the  sugar  is 
again  added  or  the  strength  and  quantity  of  the  food  is 
increased  sufficiently  to  permit  the  infant  to  make  a  gain 
in  weight  a  recurrence  of  the  diarrhoea  is  brought  about. 
This  may  be  repeated  many  times  and  is  due  to  the  fact  that 
the  infant's  tolerance  has  been  permanently  lowered  for 
these  mixtures.  The  condition  is  frequently  not  recognized 
until  repeated  unsuccessful  efforts  have  been  made  to  in- 
crease the  food  to  a  sufficient  strength.  This  is  more  apt  to 
occur  in  an  infant  who  has  previously  had  many  attacks 
or  one  prolonged  attack  of  diarrhoea. 

Differential  Diagnosis  of  Simple  Intestinal  Indigestion. — 
The  diagnosis  of  simple  intestinal  indigestion  presents 
few  difficulties.  The  onset  is  invariably  gradual,  the  infant 
going  from  bad  to  worse  on  a  feeding  that  it  is  unable  to 
digest.  There  is  no  fever ;  in  fact,  a  subnormal  temperature 
is  not  uncommon  in  infants  who  are  underfed  or  who  are 
poorly  nourished.  During  this  period  the  weight  is  station- 
ary or  there  is  a  gradually  progressive  loss  in  weight. 
Occasionally  the  weight  may  show  a  slight  increase,  but  a 
normal  gain  of  from  six  to  eight  ounces  a  week  is  never  pos- 
sible where  intestinal  indigestion  is  marked. 

The  cause  may  always  be  traced  to  a  food  which  is  un- 
suitable for  the  individual  infant. 


106  SIMPLIFIED  INFANT  FEEDING 

The  stools  vary  in  number  from  two  to  ten  or  twelve  in 
a  day,  and  an  examination  of  them  may  show  many  abnor- 
malities. They  may  be  either  yellow,  green,  or  brown  in 
-color.  They  may  be  watery  or  firm  in  consistency,  but  are 
rarely  smooth  and  homogeneous.  A  smooth  stool  may  at 
times  show  curds  and  a  certain  amount  of  mucus,  and  is 
indicative  of  intestinal  indigestion.  The  odor  of  the  stool 
is  either  normal  or  sour-smelling. 

The  reaction  is  not  significant,  for  it  may  be  either  acid 
or  alkaline,  although  it  is  more  apt  to  be  acid.  Mucus  is 
usually  present;  in  fact,  if  there  is  no  mucus  one  may  be 
certain  that  there  is  not  much  intestinal  indigestion. 

Blood  is  never  present  in  the  stools  of  intestinal  indi- 
gestion unless  it  is  due  to  some  local  condition  found  in  the 
rectum  or  anus,  as  a  fissure  or  polypus.  Curds  usually  are 
found  in  the  stools  of  infants  suffering  from  intestinal  indi- 
gestion when  milk  has  been  given  in  the  food.  Infants  who 
are  being  fed  upon  such  foods  as  malted  milk,  Nestle 's  Food, 
or  any  foods  given  without  milk,  may  have  a  marked  attack 
of  intestinal  indigestion  without  showing  curds  in  the  stool. 

Fermentative  Diarrhoea. — Although  great  advances  have 
been  made  during  recent  years  concerning  the  bacteriology 
of  the  intestinal  tract,  many  questions  still  remain  unsettled. 
It  is  known,  however,  that  the  intestines  normally  contain 
both  putrefactive  and  fermentative  bacteria,  as  well  as  other 
varieties.  Under  the  proper  conditions  it  is  possible  for  the 

1  -fermentative  bacteria  to  be  in  the  ascendency  over  the  putre- 
factive bacteria,  and  the  reverse  is  also  true.  These  proper 
conditions  are  brought  about  by  supplying  the  food  upon 
which  the  bacteria  will  thrive.  If  a  carbohydrate  diet  be 
given,  the  putrefactive  bacteria,  theoretically,  will  be 
starved  out.  If  a  protein  diet  be  supplied,  the  fermentative 
bacteria,  theoretically,  will  be  starved  out.  These  theories 
form  a  basis  for  treatment  which  from  a  practical  stand- 
point is  very  satisfactory  in  its  results. 


DIARRHOEAS  IN  BOTTLE-FED  INFANTS       107 

The  fermentative  type  of  diarrhoea  is  caused  and  aggra- 

*  x 

vated  by  the  bacteria  which  thrive  upon  carbohydrates, — 
that  is,  starch  or  sugar.  The  Finkelstein  school  attributes 
this  form  of  diarrhoea  to  carbohydrate  indigestion ;  Kendall 
has  shown  the  bacteriological  cause.  Undoubtedly  many  of 
these  cases  of  diarrhoea  are  due  to  sugar  indigestion,  and 
many  others  to  the  growth  in  the  intestinal  canal  of  bacteria 
which  live  on  carbohydrates.  This  is  an  academic  question, 
however,  which  it  is  unnecessary  to  discuss,  since  both  causes 
require  the  same  treatment — that  of  stopping  the  carbo- 
hydrates and  giving  milk  and  water  boiled  together. 

Sugar  intoxication,  according  to  the  Finkelstein  school, 
is  due  to  the  chemical  action  of  the  sugar,  but  there  can  be 
no  doubt  that,  although  this  may  be  so  in  many  instances, 
it  is  also  due  to  the  toxins  generated  by  bacterial  action. 
The  fermentative  type  of  diarrhoea  is  by  far  more  common 
than  the  putrefactive  type,  because  of  the  universal  habit  of 
giving  a  large  amount  of  sugar  to  bottle-fed  infants  and  also 

for  the  reason  that,  as  has  been  asserted  by  various  investi- 

•  .  v  ,/  r~     \ 

gators,  fermentative  bacteria  take  precedence  over  putre- 
factive bacteria,  or,  as  Kendall  expresses  it,  "carbohydrate 
shields  and  spares  protein  from  bacterial  attack." 

A  bacteriological  examination  of  the  stools  is  not  prac- 
ticable for  the  general  practitioner  and,  as  a  rule,  will  not 
be  found  necessary. 

Putrefactive  diarrhoea  is  caused  by  the  bacteria  which 
thrive  upon  protein.  It  is  rather  an  uncommon  type  of 
diarrhoea  in  bottle-fed  infants,  except  in  cases  where  the 
method  of  omitting  sugar  and  starch  in  the  treatment  of 
digestive  disturbances  has  been  followed.  The  reason  for 
this  has  already  been  stated,  namely,  that  fermentative 
bacteria  tend  to  inhibit  the  growth  of  putrefactive  bacteria, 
In  some  cases,  after  the  sugar  has  been  eliminated  from  the 
food,  the  conditions  for  the  growth  of  putrefactive  bacteria 
become  sufficiently  favorable  to  result  in  a  change  from  a 


108  SIMPLIFIED  INFANT  FEEDING 

fermentative  to  a  putrefactive  diarrhoea.  In  addition  to 
this  power  of  killing  each  other  off,  these  bacteria  seem  to 
possess  the  power  of  changing  themselves  from  fermenta- 
tive to  putrefactive  organisms.  In  other  words,  in  treating 
a  case  of  fermentative  diarrhoea  by  stopping  the  sugar  it  is 
often  observed  that  a  fermentative  diarrhoea  will  change 
into  the  putrefactive  type.  When  this  occurs  it  is  necessary 
to  give  a  pure  carbohydrate  diet  in  order  to  "starve  out'* 
the  putrefactive  bacteria. 

Differential  Diagnosis  of  Fermentative  and  Putrefactive  Diar- 
rhoea.— It  is  occasionally  difficult  to  distinguish  fermentative 
from  putrefactive  diarrhoea.  However,  it  is  easy  to  distin- 
guish either  of  the  two  from  simple  intestinal  indigestion  by 
the  fact  that  a  low  grade  of  temperature,  usually  ranging 
from  99°  to  102°  F.,  is  present  in  the  fermentative  and  putre- 
factive types.  The  onset  of  fermentative  diarrhoea  is  more 
sudden  than  that  of  simple  intestinal  indigestion. 

The  stools  of  intestinal  indigestion  have  no  abnormal 
odor,  while  those  of  the  fermentative  or  putrefactive  type 
are  either  sour  or  foul-smelling.  The  consistency  does  not 
differ  from  simple  intestinal  indigestion,  but  in  fermenta- 
tive diarrhoea  we  often  see  the  foamy  stool  if  it  is  observed 
when  freshly  passed.  Unfortunately  it  is  not  usually  pos- 
sible to  see  the  stools  until  the  foamy  appearance  has  dis- 
appeared. 

In  differentiating  fermentative  and  putrefactive  diar- 
rhoea from  the  severe  toxic  forms  of  diarrhoea,  like  dysen- 
tery, cholera  infantum,  and  sugar  intoxication,  there  need 
not  be  much  difficulty.  In  the  latter  types  the  onset  is  sudden, 
the  temperature  high  (usually  above  104°  and  even  as  high 
as  106°),  and  the  infant  looks  extremely  ill  and  grows  rap- 
idly worse  without  proper  treatment — and  sometimes  in 
spite  of  it.  In  dysentery  or  cholera  infantum  the  stools  are 
apt  to  be  more- numerous,  even  as  many  as  twenty  in  twenty- 
four  hours.  The  stools  of  dysentery  contain  blood,  and  those 


DIARRHCEAS  IN  BOTTLE-FED  INFANTS       109 

of  cholera  infantum  are  entirely  composed  of  mucus  and 
serum. 

The  problem  of  distinguishing  between  the  fermentative 
and  putrefactive  type  of  diarrhoea  is  more  difficult.  The 
onset  is  the  same,  usually  sudden,  with  a  low  degree  of  tem- 
perature— 99°  to  102° — and  the  infant  appears  only  slightly 
ill.  Apart  from  the  stools,  there  are  only  two  main  points 
of  distinction.  The  fermentative  diarrhoea  almost  always 
occurs  in  the  infant  who  has  been  fed  a  high  sugar  or  starch 
diet,  whereas  the  putrefactive  diarrheas  occur  in  infants 
who  have  been  given  strong  milk  mixtures  with  little  or  no 
sugar  or  starch  in  them,  or  in  older  infants  who  are  being  fed 
on  a  mixed  diet.  For  the  reason  that  most  formulas  contain 
a  great  deal  of  sugar  or  starch,  the  majority  of  these  diar- 
rheas are  fermentative  in  type,  and  especially  so  in  infants 
under  six  or  seven  months  of  age. 

The  therapeutic  test  is  the  second  means  of  distinguish- 
ing between  the  two.  If  there  is  any  doubt  as  to  whether  the 
diarrhoea  is  fermentative  or  putrefactive  in  type,  the  case 
should  be  treated  first  as  a  fermentative  diarrhoea — for  in- 
stance, with  a  one-third  milk  and  two-thirds  water  mixture. 
If  it  is  fermentative  diarrhoea  it  will  respond  readily  to  this 
treatment,  but  if  it  is  the  putrefactive  diarrhoea  the  treat- 
ment will  be  of  no  avail,  and  a  starch  diet,  consisting  of  a 
thick  gruel,  will  have  to  be  used  before  the  diarrhoea  is  over- 
come. It  is  usually  better,  when  using  this  therapeutic  test, 
to  give  a  boiled  milk  mixture  to  the  younger  infants,  say 
under  five  or  six  months  of  age,  and  the  gruels  to  infants 
over  that  age,  since  younger  infants  are  more  liable  to  fer- 
mentative diarrhoea  and  older  ones  to  putrefactive  diar- 
rhoeas. 

The  stools  of  fermentative  diarrhoea  are  usually  more 
numerous  than  those  of  putrefactive  diarrhoea.  The  color 
is  not  significant,  nor  is  the  presence  of  mucus  or  curds.  The 
consistency,  the  typical  foamy,  watery  stool  of  fermentative 


110  SIMPLIFIED  INFANT  FEEDING 

diarrhoea,  differs  greatly  from  that  of  the  rather  firm  stool 
ordinarily  seen  in  putrefactive  diarrhoea. 

The  reaction  of  the  stool  in  fermentative  diarrhoea  is 
add,  usually  giving  rise  to  inflamed  buttocks  and  chafing. 
The  reaction  of  the  stools  of  putrefactive  diarrhoea  is  alka- 
line, and  is  not  apt  to  be  irritating  to  the  skin. 

In  determining  the  reaction  of  the  stool  it  is  necessary 
to  get  a  stool  that  has  been  freshly  passed  and  which  is 
uncontaminated  by  urine.  In  order  to  do  this,  it  is  advis- 
able to  insert  a  small  test-tube  (with  a  hole  blown  in  the 
side)  into  the  rectum,  taking  out  the  fresh  faeces  in  this  way 
for  examination. 

The  sour  odor  of  the  stools  accompanying  fermentative 
diarrhoea  is  very  characteristic,  and  the  foul  odor  of  putre- 
factive diarrhoea  (which  resembles  the  odor  of  decayed 
meat)  is  also  very  helpful  in  differential  diagnosis. 

Mild  types  of  infectious  diarrhoea  are  more  common  than 
severe  cases,  and  are  usually  caused  by  bad  milk  or  some 
contaminated  food.  They  are  characterized  by  their  sudden 
onset  and  fever,  attended  usually  with  vomiting  and  intes- 
tinal pain,  though  one  or  both  of  these  symptoms  may  be 
lacking.  The  number  of  stools  varies  from  four  to  twelve 
in  twenty-four  hours,  a  small  number  indicating  a  compara- 
tively mild  form  of  diarrhoea.  They  may  be  foul,  sour,  or 
odorless,  and  are  more  usually  acid  than  alkaline.  They 
are  generally  green  and  watery — sometimes  frothy,  due  to 
gas — and  contain  mucus,  curds,  and  undigested  food.  The 
severity  of  the  attack  depends  upon  the  virulence-  of  the 
infection,  the  previous  health  of  the  infant,  and  the  prompt- 
ness with  which  the  cause  can  be  located  and  removed  and 
the  proper  treatment  instituted. 

Dysentery  (Synonymous  with  Ileocolitis,  Infectious  Diar- 
rhoea).— Up  to  the  present  time  several  different  microor- 
ganisms have  been  isolated  from  the  stools  of  infants  having 


DIARRHOEAS  IN  BOTTLE-FED  INFANTS       111 

dysentery,  among  which  are  the  Flexner  dysentery  bacillus, 
the  Shiga  dysentery  bacillus,  the  colon  bacillus,  and  the 
streptococcus.  According  to  Kendall,  these  bacteria  no 
longer  produce  toxins  when  the  diet  is  exclusively  carbo- 
hydrate. This  explains  why  the  purely  carbohydrate  diet 
has  been  successful  in  combating  certain  cases  of  dysentery. 

These  are  the  cases  that  have  been  variously  called  ileo- 
colitis,  dysentery,  cholera  infantum,  and  possibly  some  of 
the  cases  classified  by  Finkelstein  as  intoxication.  There  is 
a  history  of  a  sudden  onset,  high  temperature,  prostration, 
vomiting,  and  extremely  numerous  loose  stools  composed 
of  mucus  and  blood. 

The  diagnosis  of  dysentery  presents  few  difficulties.  An 
infant  who  has  previously  been  well,  or  one  who  has  had  in- 
testinal indigestion,  is  suddenly  attacked  with  a  severe  ill- 
ness. The  temperature  ranges  from  104°  to  106°,  there  is 
uncontrollable  vomiting  at  the  onset  and  a  rapid  loss  of 
weight.  The  stools  are  numerous,  ten  or  twenty — or  even 
more — in  twenty-four  hours,  and,  after  the  fecal  matter 
which  was  in  the  bowels  at  the  onset  has  been  evacuated,  are 
composed  almost  entirely  of  blood  and  mucus,  each  evacua- 
tion being  accompanied  by  tenesmus. 

Cholera  Infantum. — It  has  been  questioned  by  some 
authorities  whether  cholera  infantum  should  be  dignified  by 
a  classification  of  its  own,  since,  as  yet,  no  bacteria  have 
been  isolated  as  its  direct  cause.  It  would  probably  be  better 
to  call  this  condition  intoxication  were  it  not  for  the  fact 
that  it  might  be  confused  with  Finkelstein 's  sugar  intoxi- 
cation. 

Clinically,  cholera  infantum  has  a  very  definite  entity. 
It  is  characterized  by  a  sudden  onset,  high  rise  in  tempera- 
ture, almost  continuous  vomiting,  profuse  diarrhea,  stools 
which  quickly  lose  their  fecal  character  and  are  white  in 
color,  like  rice  water,  and  consist  almost  entirely  of  serum 


112  SIMPLIFIED  INFANT  FEEDING 

and  mucus.  The  fluids  of  the  body  are  rapidly  drained, 
collapse  follows,  often  with  coma,  and  death  within  from 
twelve  to  thirty-six  hours  of  the  onset. 

Sugar  Intoxication. — Finkelstein  and  his  coworkers,  Meyer 
and  Leopold,  have  proved  conclusively  that  milk-sugar  can, 
of  itself,  produce  symptoms  of  intoxication.  They  have 
brought  on  fever  and  symptoms  of  sugar  intoxication  by 
giving  large  amounts  of  sugar  to  infants  who  were  particu- 
larly vulnerable  to  its  toxic  effect,  producing  the  so-called 
"Sugar  fever."  Leopold  and  Eeuss  have  experimentally 
produced  "Sugar  fever"  in  young  infants.  The  symptoms 
are  fever,  diarrhoea,  and  sometimes  vomiting,  deep,  slow 
respirations,  stupor  with  a  typical  and  characteristic  facies, 
— that  is,  the  eyes  sunken  and  staring,  the  mouth  open  and 
twitching.  Sugar  may  also  be  recovered  in  the  urine. 

Marasmus  (lost  power  of  assimilation,  decomposition, 
atrophy) . — This  condition  is  so  well  known  that  ^it  hardly 
needs  an  explanation.  According  to  Grulee,  it  is  "a  chronic 
state  of  malnutrition  seen  in  infants,  characterized  by  ina- 
bility to  so  assimilate  the  food  given  as  to  gain  weight  prop- 
erly, by  subnormal  temperature,  emaciation,  and  by  a  greatly 
lowered  resistance."  The  name  "decomposition"  has  been 
given  by  Finkelstein  to  this  well-known  condition,  but  it  only 
serves  to  confuse  the  nomenclature. 

Diarrhoea  from  Cathartics. — Diarrhoea  is  frequently  caused 
by  the  continued  and  daily  use  of  cathartics,  and  it  is  very 
important  to  recognize  this  form  in  order  to  correct  it. 

Mechanical  Diarrhoea. — This  class  of  diarrhoea  has  grown 
smaller  with  our  increased  knowledge  of  the  principles  of 
infant  feeding.  It  was  formerly  thought  that  the  curds  and 
various  other  constituents  of  the  food  acted  mechanically 
only  through  irritation  of  the  bowel  and  thus  caused  the 
diarrhoea.  Mechanical  diarrhoea  is  now  limited  to  cases 
occurring  in  infants  and  older  children  who  have  been  given 
some  specific  indigestible  article  of  food,  such  as  bananas, 


DIARRHCEAS  IN  BOTTLE-FED  INFANTS       113 


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114  SIMPLIFIED  INFANT  FEEDING 

under-cooked  starches,  or  the  various  other  foods  unfit  for 
children. 

This  form  of  diarrhoea  has  also  been  the  cause  of  the 
absurd  practice  of  treating  all  diarrhoeas  with  a  cathartic 
and  a  period  of  starvation.  Such  treatment  is,  of  course, 
necessary  in  mechanical  diarrhoea. 

Other  Organic  Causes. — Typhoid  fever,  amoebic  dysenteryr 
tuberculosis,  ulcer,  and  intussusception  are  noted  here  only 
to  make  the  classification  complete.  A  discussion  of  them 
would  be  out  of  place  in  this  book. 


CHAPTER  IX 

TREATMENT  OF  DIARRHOEAS  IN 
BOTTLE-FED  INFANTS 

DIARRHOEA  in  bottle-fed  infants  is  as  often  the  result  of 
intestinal  indigestion  or  non-digestion,  due  to  incorrect 
feeding,  as  it  is  to  bacterial  infection. 

By  "incorrect  feeding"  is  meant  a  food  which  is  not 
suitable  for  the  individual  infant  at  a  particular  time,  and 
not  necessarily  a  food  that  is  improper  under  other  circum- 
stances. 

Formerly  all  cases  of  diarrhoea  were  treated  in  a  routine 
manner  with  a  cathartic,  followed  by  a  period  of  starvation, 
because  all  were  thought  to  be  due  to  a  bacterial  invasion 
from  sources  outside  the  body,  and  it  was  believed  that  the 
undigested  food  within  the  bowel  should  be  removed  by  this 
means.  Since  only  a  portion  of  the  cases  of  diarrhoea  is 
due  to  an  infection,  and  since  the  bowel  usually  is  emptied 
very  thoroughly  of  its  own  accord  without  the  assistance 
of  cathartics,  it  is  not  advisable  to  use  them  in  every  case 
of  diarrhoea.  In  selected  cases  a  cathartic  followed  by  a 
period  of  starvation  is  a  very  useful  procedure,  but  both 
cathartics  and  starvation  have  done  a  great  deal  of  harm. 

It  would  seem  most  illogical  to  treat  all  cases  of  diar- 
rhoea in  the  same  routine  manner,  and  the  author's  experi- 
ence has  shown  that  the  results  of  such  routine  treatment 
are  not  successful.  In  older,  stronger  infants  cathartics 
aggravate  the  diarrhoea  when  the  bowel  is  already  irritated 
by  intestinal  indigestion,  and  with  small,  emaciated  infants, 
who  have  no  strength  to  lose  from  starvation,  it  is  still  more 
harmful  to  starve  them  and  to  further  irritate  the  bowels 
with  cathartics.  This  treatment  is  often  the  means  of  reduc- 

115 


116  SIMPLIFIED  INFANT  FEEDING 

ing  an  infant  to  such  a  condition,  that  recovery  from  the  loss 
of  strength  which  it  has  cost  is  an  impossibility. 

The  author  recalls  a  case,  seen  some  years  ago,  which  was 
typical  of  the  results  obtained  with  the  older  plan  of  treat- 
ment. 

It  was  a  weak,  pale,  emaciated  infant  of  two  or  three 
months  of  age  who  had  never  done  well  upon  its  feedings  and 
who  had  had  frequent  loose,  curdy,  mucous  stools  from  intes- 
tinal indigestion  for  the  greater  part  of  its  life.  At  that  time 
every  infant  with  diarrhoea  was  first  " cleaned  out"  with  a 
dose  of  castor  oil,  and  was  then  given  albumin  water  for 
twenty-four  hours.  This  baby  received  the  routine  treat- 
ment, and,  as  might  have  been  expected,  lost  five  or  six 
ounces  in  weight  as  a  result  without  much  improvement  in 
the  condition  of  the  stools.  Milk  feedings  were  then  insti- 
tuted, and  at  the  end  of  the  week  the  stools  were  as  bad  as 
ever.  A  cathartic  and  a  day  of  starvation  was  again  used, 
resulting  in  further  loss  of  weight  and  strength.  This 
process  was  repeated  three  or  four  times,  with  a  loss  of 
weight  each  time,  until  the  mother  took  it  into  her  own  hands, 
stopped  further  cathartics,  and  fed  the  baby  very  success- 
fully herself. 

In  the  light  of  our  present  knowledge,  such  diarrhoeas 
could  now  be  controlled  inside  of  three  or  four  days  by  the 
proper  dietetic  measures  and  without  the  use  of  any  cathartic 
whatever. 

It  is  absolutely  necessary  to  stop  a  diarrhoea,  even  if  it 
is  very  mild  in  character,  before  giving  an  infant  a  food 
of  the  proper  quality  and  quantity  to  make  a  gain  in  weight. 
While  we  are  getting  control  of  the  bowels  and  until  the 
digestion  is  straightened  out  an  infant 's  actual  caloric  needs 
must  be  disregarded. 

The  treatment  of  diarrhoea  in  bottle-fed  infants  is  almost 
entirely  dietetic.  Drugs  are  of  minor  importance,  and, 


DIABRHCEAS  IN  BOTTLE-FED  INFANTS      117 

even  when  they  are  employed,  a  proper  feeding  must  still 
be  instituted. 

There  are  three  different  methods  of  treating  diarrhosa, 
and  each  has  its  own  indications. 
I.  Protein  Diet : 

(a)  One-third  milk  and  two-thirds  water  boiled 

together  (no  sugar). 

(fe)  One-half  fat-free  milk  (skimmed  milk)  and  one- 
half  water  boiled  together  (no  sugar). 
(c)  Protein  Milk  (Eiweiss  Milch). 
II.  Carbohydrate  Diet: 

Gruels  and  breadstuffs. 
III.  Cathartic  and  Starvation. 


CHAPTER  X 

FIRST  METHOD  OF  TREATING  DIARRHOEA 

PROTEIN  DIET 

(a)  Stop  all  sugar.  (c)  Boil  the  milk  and  water 

(b)  Feed  one-third  milk  and  together. 

two-thirds    water,    or     (d)  Avoid  cathartics. 

one-half  fat-free  milk     (e)  Use  protein  milk. 

and  one-half  water. 

Indications. — (1)  Simple  indigestion  from  fat,  sugar,  pro- 
teid,  or  starch;  (2)  underfeeding;  (3)  overfeeding;  (4)  fer- 
mentative infectious  diarrhrea, 

(a)  Stop  All  Sugar. — Sugar  is  undoubtedly  the  most  laxa- 
tive constituent  of  the  bottle-fed  infant's  food.  It  is  also  the 
element  of  the  food  that  most  frequently  causes  indigestion. 
Those  who  have  treated  many  cases  of  diarrhoea  by  omitting 
artificial  sugar  from  the  food  can  have  no  doubt  of  this  fact. 
Although  sugar  does  not  always  act  as  a  laxative  when  given 
to  infants  who  are  constipated  (except  in  cases  where  the 
sugar  is  already  deficient),  it  is  a  laxative  where  there  is  a 
tendency  toward  diarrhoea.  It  is  well,  therefore,  not  to  give 
any  sugar  at  all  until  the  stools  have  become  normal  and 
have  remained  normal  for  at  least  three  days. 

The  mistake  is  often  made  of  reducing  the  sugar  in  quan- 
tity instead  of  stopping  it  altogether.  An  exception  to  this 
rule  must  be  made  when  an  infant  has  been  so  weakened 
by  wrong  feeding  or  lack  of  sugar  that  it  is  in  a  state  of 
collapse,  in  which  case  the  lack  of  sugar  would  be  dangerous. 
It  must  be  ascertained  whether  or  not  the  mother  gives 
sugar  and  water  between  feedings,  which  habit  should  be 
prohibited.  The  objection  is  usually  offered  that  the  infant 
will  not  take  any  feeding  without  sugar,  because  it  is  accus- 
tomed to  the  sweetened  food.  It  is  advisable  to  explain 
that  the  infant  will  take  its  food  when  sufficient  appetite  has 

118 


TREATMENT  OF  DIARRHCEA  119 

been  acquired,  and  that  it  is  not  necessary  to  give  water  be- 
tween feedings  except  to  stop  excessive  crying.  Saccharine 
may  be  added  to  tine  water  or  to  the  food. 

(b)  One-third  whole  milk  and  two-thirds  water  is  advised  as 
a  routine  mixture,  as  it  gives  an  infant  who  has  been  underfed 
sufficient  nourishment  for  a  short  period  while  the  diarrhoea 
is  being  controlled.  The  infant  who  has  been  underfed  will 
not  lose  as  much  weight  as  upon  an  exclusive  gruel  diet,  and 
the  infant  who  has  been  overfed  or  has  considerable  indi- 
gestion from  wrong  feeding  will  do  well  upon  it,  because 
it  gives  the  stomach  and  intestines  a  rest  without  starvation 
measures. 

Although  one-third  milk  and  two-thirds  water  may  be 
used  as  a  routine,  very  small  infants  under  six  pounds  in 
weight  who  have  a  bad  diarrhoea,  and  possibly  those  who 
have  been  fed  on  foods  not  containing  milk,  may  be  started 
with  one-quarter  milk  and  three-quarters  water,  which  should 
be  rapidly  increased  as  the  diarrhoea  improves.  On  the  other 
hand,  older  and  larger  infants  who  have  formerly  been  fed 
strong  milk  mixtures  and  who  are  not  suffering  with  a 
severe  form  of  diarrhoea  may  have  one-half  milk  and  one- 
half  water.  Whole  milk  should  be  used,  and,  since  top  milks 
have  been  in  favor  so  long,  it  is  always  wise  to  instruct  a 
mother  to  mix  the  milk  thoroughly  by  pouring  it  into  a 
pitcher  and  back  into  the  bottle.  In  the  more  severe  types  of 
diarrhoea,  particularly  during  the  warm  weather,  fat-free 
milk  or  skimmed  milk  must  be  used  in  the  mixture  in  place 
of  the  full  milk.  When  good,  clean,  separated  milk  can  be 
obtained  it  is  advisable  to  use  it,  since  all  of  the  fat  can  be 
removed  mechanically  by  the  separator.  The  Walker  Gor- 
den  Laboratories  supply  such  milk.  If  this  is  not  procurable, 
the  cream  may  be  less  thoroughly  removed  in  the  home  by 
the  use  of  the  Chapin  dipper.  A  quart  bottle  of  milk  is 
allowed  to  stand  undisturbed  until  all  the  cream  has  risen  to 
the  top  of  the  bottle  and  there  is  a  definite  line  between  the 
cream  and  the  bottom  milk  (cream  line).  A  Chapin  dipper 


120  SIMPLIFIED  INFANT  FEEDING 

(which  has  a  bowl  of  the  correct  size  to  pass  through  the  neck 
of  the  bottle  and  a  long  handle)  should  be  used  to  dip 
off  the  cream.  Dip  off  six  ounces  (the  dipper  holds  one 
ounce).  The  bottom  milk  will  be  skimmed  milk,  which  is 
used  according  to  the  accompanying  directions. 

Barley  gruel  as  a  diluent  does  not  always  act  as  well  as 
plain  water.  Some  infants  do  not  digest  gruels  well,  espe- 
cially very  small,  weak  infants.  Since  this  is  true,  and  since 
the  addition  of  gruels  does  not  make  the  proteids  more  di- 
gestible, it  is  best  not  to  use  them  except  for  older  infants. 

(c)  Boil  the  Milk  and  Water  Together.— /Formerly  it  was 
believed  that  boiled  milk  was  more  difficult  to  digest  than 
raw  milk.  This  is  not  a  fact,  for  it  has  been  proved  con- 
clusively that  boiled  milk  is  more  easily  digested  than  raw 
milk  (see  page  275).  If  the  milk  has  been  properly  boiled, 
tough,  hard  curds  do  not  form  in  the  stomach,  nor  are  they 
seen  in  the  stools.  The  author  has  attempted,  in  many  in- 
stances, to  control  diarrhea  with  unboiled  mixtures,  and 
most  often  failed. to  do  so.  It  should  be  distinctly  under- 
stood that  the  milk  is  not  boiled  to  kill  bacteria,  but  to  make 
the  milk  itself  more  digestible.  It  is  advisable1  to  use  certi- 
fied milk,  with  a  low  bacterial  count,  if  it  is  procurable. 

Boiled  milk  is  more  effective  when  the  milk  and  water 
are  boiled  vigorously  together.  The  following  directions 
should  be  carefully  carried  out:  Measure  out  the  required 
number  of  ounces  of  water,  put  into  a  saucepan  and  bring 
it  to  an  active  boil  While  the  water  is  boiling,  pour  in  the 
required  number  of  ounces  of  milk  and  bring  the  mixture 
to  the  boiling-point  as  rapidly  as  possible,  stirring  all  the 
time  so  that  a  scum  will  not  form  upon  the  top.  This  scum 
is  undesirable,  for  the  reason  that  it  stops  up  the  nipples  if 
retained,  and  if  discarded  carries  with  it  a  certain  amount  of 
food  value,  as  it  is  made  up  of  fat  and  albuminous  proteid. 
Boil  actively  for  three  minutes  after  it  has  once  come  to  a 
boil.  Pour  immediately  into  clean  feeding  bottles,  using  as 


TREATMENT  OF  DIARRHOEA  121 

many  bottles  as  there  are  to  be  feedings  in  twenty-four 
hours.  Cool  them  as  quickly  as  possible  in  cold  water  in 
the  summer  time  and  out  of  the  window  in  the  winter  time, 
and  then  place  directly  upon  the  ice  until  used. 

It  is  best  to  continue  giving  the  boiled  milk  for  two  or 
three  weeks  after  the  diarrhoea  has  stopped.  Some  infants 
will  always  do  better  on  the  boiled  milk  and  get  up  a  diar- 
rhoea as  soon  as  the  boiling  is  discontinued.  It  will  be  some- 
times argued  that  an  infant  fed  on  boiled  milk  over  a  pro- 
longed period  will  develop  scurvy.  This  danger  can  be 
obviated  by  the  simple  expedient  of  giving  orange  juice 
between  feedings  after  it  has  been  found  necessary  to  give 
boiled  milk  longer  than  two  months. 

(d)  Avoid  Cathartics. — Abt  has  shown  that  calomel  ad- 
ministered to  normal,  healthy  babies  with  no  digestive  dis- 
turbances will  cause  blood  to  appear,  microscopically  at 
least,  in  the  stools.  In  a  series  of  twenty  cases  he  found  this 
to  be  universally  true.  It  can  readily  be  seen  then  how  much 
more  harm  calomel  will  do  when  the  bowels  are  already  irri- 
tated, as  during  a  diarrhoea.  Castor  oil,  although  not  so 
violent  in  its  action  as  calomel,  is  also  injurious  in  its 
effects  in  certain  cases.  Clinically  it  has  been  demon- 
strated that  the  various  forms  of  diarrhoea  mentioned  in 
this  chapter  can  be  controlled  more  easily  without  the  use 
of  a  cathartic. 

INDICATIONS  FOB  THE  USE  OF  THE  FIRST  METHOD 

Two-thirds  of  the  entire  number  of  cases  of  diarrhoea 
in  bottle-fed  infants  will  be  found  to  be  amenable  to  this 
method  of  treatment. 

(1)  Simple  Intestinal  Indigestion  from  Fat,  Sugar,  Proteid, 
and  Starch. — This  method  is  particularly  useful  in  treating 
undersized,  young  infants  who  have  never  done  well  on  any 
food  and  who  have  always  had  intestinal  indigestion,  as 
indicated  by  the  presence  of  curds  and  mucus  in  their  stools. 


122  SIMPLIFIED  INFANT  FEEDING 

CASK  XVIII 

(Illustrating  the  use  of  the  first  method  in  a  case  of  simple  intestinal  indi- 
gestion ) 

April  24:     Age,  3  months.     Weight,  10  Ib.  13  oz. 
General  Condition.  —  Fairly  well  nourished,  active,  cries  night  and  day;  needa 

from  50  to  55  calories  per  pound  per  day. 
Stools.—  For  two  weeks,  eight  or  ten  a  day,  yellow,  watery,  with  many  curds 

and  much  mucus,  no  blood. 
Vomiting.  —  None. 
Appetite.  —  Ravenous. 
Sleep.  —  Very  little. 
Temperature,  98.6°  F. 
Chief  Complaint.  —  Diarrhoea. 

Previous  Food: 

Top  milk   (7  per  cent,  fat)  .  .     8  oz.  Fed  4  oz.  every  3  hours,  7 

Water  ......................  19  oz.  feedings  in  24  hours. 

Lime  water  .................     1  oz. 

Milk  sugar  .................  5  teaspoonfula. 

Treatment  .  —  Food  prescribed  : 

Whole  milk  .........    12  oz.  |      .  Divide  into  7  bottles.     Feed  5+   oz. 

Water  ..............  24  oz.  j  b<  every  3  hours  at  6,  9,  12  A.M.,  3,  6, 

Sugar  ..............     0  oz.  9  P.M.,  and  2  A.M. 

April  29   (5  days  later)  :     Weight,  10  Ib.  12  oz. 

Loss,  1  oz. 

General  Condition.  —  The  same. 

Stools.  —  Two  yellow,  smooth,  hard,  no  mucus,  no  curds. 
Vomiting.  —  None. 
Appetite.  —  Ravenous. 
Sleep.  —  Poor. 

Treatment.  —  Food  prescribed:  Increase  milk   (in  previous  formula)   one  ounce 

each  day,  decreasing  the  water  one  ounce  each  day  until  the  formula  is: 
Milk  ...............    18  oz.          .  Divide  into  7  feedings.     Feed  5+  oz. 


. 
Water  ..............    18  oz.      boiled          every  3  hours  as  before. 

Dextri-maltose  ......    y4  oz. 

This  infant  had  always  been  fairly  well  fed  according  to  the  old  standard 
of  top  milk.  The  milk-sugar  or  the  fats  had  evidently  caused  a  diarrhoea. 
In  three  days  the  stools  became  normal  with  the  boiled  milk  and  water  mixtures 
without  sugar.  Subsequently  the  sugar  was  increased  a  quarter  of  an  ounce 
•at  a  time  up  to  1^  ounces  without  any  recurrence  of  the  diarrho?a. 


TREATMENT  OF  DIARRHCEA  123 

(2)  Underfeeding. — The  first  method  is  also  very  useful 
in  diarrhoea  of  infants  who  have  been  fed  over  a  prolonged 
period  of  time  upon  barley  gruel  without  milk,  upon  malted 
milk,  or  any  of  the  foods  which  are  given  without  milk.  It  is 
a  frequent  occurrence  to  be  called  to  see  an  infant  with  diar- 
rhcea  that  has  been  fed  exclusively  upon  barley  gruel  for  two 
or  three  weeks.  The  gruel  has  been  wrongly  continued  in 
the  belief  that  if  the  infant  could  not  digest  so  simple  a  food 
as  gruel  it  certainly  could  not  digest  milk. 

CASE  XIX 

(Illustrating  the  use  of  the  first  method  in  a  case  of  underfeeding) 
May  23:     Age,  5  months.     Weight,  13  Ib. 

General  Condition. — Fairly  well  nourished,  color  fair,  languid. 

Stools. — For  two  weeks,  eight  or  ten  a  day,  small,  brown,  watery,  muous,  no 
curds. 

Vomiting. — None. 

Appetite. — Poor. 

Sleep. — Fair. 

Temperature,  98°  F. 

Chief  Complaint. — Diarrhoea. 

Previous  Food. — This  infant  was  breast-fed  until  one  month  ago,  when  the 
mother  died.  Various  modifications  of  top-milk  mixtures  were  given  until 
two  weeks  ago,  when  diarrhoea  commenced,  for  which  reason  the  baby  waa 
put  upon  barley  gruel.  It  had  lost  one  pound  in  weight  during  this  period. 

Treatment. — Food  prescribed : 

Milk 12  oz.  |  Divide  into  7  bottles.     Feed  5+   oz. 

Water 24  oz.  }  b  every  3  hours  at  6,  9,  12  A.M.,  3,  6, 

Sugar 0  9  P.M.,  and  2  A.M. 

Increase  the  milk  and  decrease  the  water  one  ounce  each  day  until  the 
next  visit. 

May  28   (5  daya  later)  :     Weight,  13  Ib. 
General  Condition. — The  same. 

Stools. — For  last  two  days,  two  yellow,  smooth,  soft,  homogeneous,  no  curds. 
Vomiting. — None. 

Appetite. — Good,  takes  all  the  food. 
Sleep. — Same  as  before. 

Treatment. — Food  given: 

Milk 20  oz.       Divide  into  7  bottles.     Feed  5+ 

Water 20  oz.  oz.  every  3  hours  as  before. 

Cane  sugar 14  oz. 


124  SIMPLIFIED  INFANT  FEEDING 

This  infant  continued  to  have  normal  stools  and  made  a  continuous  gain 
fa  weight  with  a  gradual  increase  of  the  milk  and  sugar.  The  method  of 
increasing  the  milk  one  ounce  each  day  and  decreasing  the  water  one  ounce 
each  day  may  be  occasionally  used  when  it  is  not  practicable  to  see  the  infant 
every  day,  and  when  it  is  badly  in  need  of  nourishment. 

It  is  not  uncommon  to  see  an  infant  who,  because  it  has 
not  seemed  to  digest  the  food  in  the  proper  strength,  has 
been  given  a  food  which  is  a  little  more  dilute.  The  stools 
still  show  that  there  is  intestinal  indigestion,  because  the 
tolerance  has  not  been  increased  by  eliminating  the  element 
of  the  food  which  is  causing  the  disturbance,  and  the  food  is 
diluted  again.  This  process  of  weakening  the  food  is  re- 
peated again  and  again  until  its  nutritional  value  is  far 
below  the  infant's  needs,  and  the  diarrhoea  still  keeps  up, 
the  tolerance  at  the  same  time  being  gradually  lowered. 

CASE  XX 

( Illustrating  the  use  of  the  first  method  in  a  case  of  indigestion,  underfeeding, 
and  lowered  tolerance) 

December  31:     Age,  4  weeks.     Birth  weight,  5  Ib. 

Present  weight,  4  Ib.  5  oz. 
Loss  since  birth,  11  oz. 
General  Condition. — Emaciated,  pale,  languid,  feeble  cry;  needs  65  calories  per 

pound  per  day. 

Stools. — Since  birth,  five  or  six  green,  mucous,  watery  stools,  with  curds. 
Vomiting. — None. 

Appetite. — Leaves  one  ounce  four  or  five  times  a  day. 
Bleep. — Good  most  of  the  time. 
Temperature,  97°  F. 
Chief  Complaint. — Not  gaining  in  weight ;  diarrhoaa. 

Previous  Food. — High  fat  mixtures  gradually  weakened  to 
Top  2  oz.  of  two  quart  bottles  of  milk.     4  oz. 

Lime  water   4  oz.     Fed  2y2  oz.  every  2y2  hours,  8 

Water  12  oz.         feedings  in  24  hours. 

Sugar    0 

Treatment. — Food  prescribed : 

Milk 10  oz.  •»  Divide  into   10  bottles.     Feed  3 

Water 20  oz.  [  ^"^  oz.  every  2  hours,  10  feedings 

Sugar 0  in  24  hours. 


TREATMENT  OF  DIARRHCEA  125 

January  3    (3  days  later)  :     Weight,  4  Ib.  5  oz. 

No  ^in  or  lo98' 


General  Condition.—  The  same. 
Stools.  —  Three  yellow,  smooth,  soft,  homogeneous,  no  mucus  or  curdg. 
Vomiting.  —  None. 

Appetite.  —  Good,  takes  all  the  food. 
Sleep.  —  Good. 

Treatment  .  —  Food  prescribed  : 
Milk  ..........    10  oz.   (200  cals.)  )  Divide  into  10  feedings.     Feed 

Water  ........   20  oz.  j"  boiled  3  Oz.  every  2  hours,  10  feed- 

Dextri-maltose  .   %  °z-    (30  cals.)  ings  in  24  hours. 

(230  calories,  or  approximately  55  calories  per  pound.) 

January  7    (4  days  later)  :     Weight,  4  Ib.  8  oz. 

Gain,  3  oz. 
General  Condition.  —  The  same. 

Stools.  —  The  same.  . 

Vomiting.  —  The  same. 
Appetite.  —  The  same. 
Sleep.  —  The  same. 

This  infant  gained  almost  continuously  and  doubled  its  weight  after  3% 
months,  with,  of  course,  a  gradual  increase  in  the  strength  of  the  food. 

This  case  is  illustrative  of  how  a  very  weak  infant,  underfed  all  its  life 
with  top  milks,  may  be  relieved  of  its  intestinal  indigestion  in  three  days.  It 
•will  be  noticed  that  this  infant  had  lost  11  ounces  since  birth  and  was  too  weak 
to  cry  lustily.  In  this  case,  fortunately,  there  was  no  vomiting. 

(3)  Overfeeding.  —  The  first  method  may  also  be  used  suc- 
cessfully in  some  cases  in  treating  older  infants  who  are  not 
emaciated  but  who  have  been  overfed,  using  half  milk  and 
half  water  for  infants  who  are  already  accustomed  to  strong 
milk  mixtures.  It  is  optional,  however,  with  these  cases, 
whether  the  first  or  second  method  is  employed. 

CASE  XXI 
(Illustrating  the  use  of  the  first  method  in  a  case  of  overfeeding) 

June  6:     Age,  6  months.     Weight,  18  Ib.  14  oz. 
General  Condition.  —  Fat,  pale,  slightly  rhachitic;  needs  from  40  to  45  calories 

per  pound  per  day. 
Stools.  —  For  two  weeks,  six  or  eight  green,  watery,  with  much  mucus  and  soft 

curds. 

Vomiting.  —  None. 

Appetite.  —  Poor,  leaves  half  of  the  food. 
Bleep.  —  Poor,  cries  a  good  deal. 
Temperature,  98.6°  F. 
Chief  Complaint.  —  Diarrhoea. 


126  SIMPLIFIED  INFANT  FEEDING 

Previous  Food: 

Undiluted  unboiled  milk  with  1  grain 

citrate  of  soda  to  the  ounce.     This      Fed  8  oz.  every  3  hours,  6  feedings 
had  been  the  food  since  birth,  given  in  24  hours, 

in  increased  quantities. 

Three  days  ago  changed  to: 

Milk 32  oz.       Fed  8  oz.  every  3  hours,  6  feed- 
Barley  gruel 16  oz.          ings  in  24  hours. 

Cane  sugar 1  oz. 

Treatment. — Food  prescribed: 

Milk 24  oz.  |      .  Divide  into  6  bottleg.    Feed  8  oz. 

Water 24  oz.  j  boiled  every  3  hours. 

June  9    (3  days  later)  :     Weight,  18  Ib.  12  oz. 

Loss,  2  oz. 

General  Condition. — The  same. 

Stools. — Three  yellow,  smooth,  soft,  homogeneous,  no  mucus,  no  curds. 
Vomiting. — None. 

Appetite. — Good,  takes  all  the  food. 
Sleep.— Better. 

Treatment. — Food  prescribed : 

Milk 28  oz.  }      .  Feed  8  oz.  every  3  hours,  6  feed- 
Water 20  oz.  \  """^  ings  in  24  hours. 

Sugar 0 

June  12   (3  days  later)  :     Weight,  18  Ib.  12  oz. 

No  gain  or  loss. 
General  Condition. — The  same. 

Stools. — One  yellow,  hard  (constipated),  homogeneous. 
Vomiting. — None. 

Appetite. — Good,  takes  all  the  food. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk 30  oz.  1  Divide  into  6  feedings.  Feed  8  oz. 

Water 18  oz.  j  boiled          every  3  hours  as  before. 

Cane  sugar ya  oz. 

The  digestion  remained  normal  and  an  increase  in  weight  followed  as 
soon  as  enough  sugar  could  be  added  to  supply  the  infant's  caloric  needs. 


TKEATMENT  OF  DIARRHOEA  127 

(4)  Fermentative  Diarrhoea.—  The  treatment  for  this  form 
of  diarrhoea  is  the  same  in  all  respects  as  that  employed  in 
cases  of  simple  sugar  and  fat  indigestion. 

CASE  XXII 
(Illustrating  the  use  of  the  first  method  for  fermentative  diarrhoea) 

July  28:     Age,  3  months  1  week.     Weight,  10  Ib.  12  oz. 
General  Condition.  —  Fairly  well  nourished,  pale,  skin  elastic,  musculature  poor 

(flabby).     Needs  from  50  to  55  calories  per  pound  pec.  day. 
Stools.  —  For  two  weeks,  five  or  six  green,  foamy,  watery,  sour-smelling,  some 

mucus,  no  curds. 

Vomiting.  —  Three  or  four  times  a  day. 
Appetite.  —  Hungry. 
Sleep.  —  Poor. 
Temperature,  101°  F. 
Chief  Complaint.  —  Diarrhoea. 

Previous  Food: 

Eagle  Brand  condensed  milk.      1  teaspoonful       Fed   8   oz.   every  2  hours,   12 
Water     ...................    20  teaspoonf  uls         feedings  in  24  hours   (  mak- 

ing about  80  oz.  of  food  a 

day). 
Treatment.  —  Food  prescribed  : 

Milk  ...........    15  oz.  |      .  Divide  into  7  bottles.     Feed  5V2 

Water  ..........   25  oz.  J    '  ounces  every  3  hours. 

Sugar  ..........     0 

August  1    (4  days  later)  :     Weight  10  Ib.  10  oz. 

Loss,  2  oz. 

General  Condition.  —  As  at  last  date. 
Stools.  —  Three  yellow,  smooth,  no  mucus,  no  curds. 
Vomiting.  —  None. 
Appetite.  —  Hungry. 
Sleep.  —  Good. 
Temperature,  98°  F. 


Treatment . — Food  prescribed : 

Milk 11 

Water 22 

Sugar 0 


Milk  ...........    18  oz.  ^       .  Divide  into  7  feedings.     Feed  ae 

Water..  .   22  oz.    f  l3oiled  before. 


128 

August  3   (2  days  later)  :     Weight,  10  Ib.  12  oz. 

Gain,  2  oz. 

General  Condition. — AB  at  last  date. 
Stools. — One  normal. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Fair. 

Treatment. — Food  prescribed: 

Milk 18  oz.      Divide  into  7  feedings.     Feed  as 

Water 22  oz.          before. 

Dextri-maltose %  oz. 

This  infant  continued  to  have  normal  stools  throughout  the  summer,  and, 
after  the  sugar  and  milk  could  be  increased  in  quantity,  gained  progressively 
in  weight. 

PBOTEIN  MILK  (Eiweiss  milch,  albumin  milk,  casein 
feeding) . 

Indications. — (1)  Simple  intestinal  indigestion  and  fer- 
mentative diarrhoea,  severe  or  of  long  standing;  (2)  any 
ease  of  diarrhoea  in  which  the  other  methods  fail  after  a 
thorough  and  persistent  trial;  (3)  dysentery  and  severe  in- 
fectious diarrhoeas  after  the  initial  treatment  given  under 
the  third  method;  (4)  selected  cases  of  marasmus. 

Protein  milk  after  Finkelstein  's  formula  is  a  food  made 
by  adding  the  curds  of  one  quart  of  milk  (the  whey  having 
been  separated  and  discarded)  to  one  pint  of  water  and 
one  pint  of  buttermilk. 

Finkelstein 's  original  idea  was  to  make  a  food  containing 
as  little  sugar  and  salts  as  possible,  believing  that  under 
certain  conditions  the  lactose  and  the  salts  contained  in  the 
milk  itself  were  the  harmful  ingredients  of  cow 's  milk.  By 
coagulating  the  milk,  the  curds,  containing  the  casein  protein 
and  fat,  are  retained  and  the  whey,  which  is  made,  up  of  the 
albuminous  protein,  sugar,  salts  and  water,  is  discarded, 
all  but  a  small  portion  of  the  sugar  and  salts  being  soluble 
in  the  whey.  Buttermilk  also  has  a  low  sugar  content  be- 
cause part  of  the  sugar  has  been  destroyed  during  the 
process  of  fermentation.  When  this  mixture  is  completed 


TREATMENT  OF  DIABEHCBA  129 

we  have  a  food  with  about  1  per  cent,  of  sugar,  a  very  high 
protein  content  (chiefly  casein  protein),  and  a  little  less  fat 
than  is  found  in  undiluted  cow's  milk. 

Protein  milk  is  useful  in  severe  cases  of  intestinal  indi- 
gestion where  the  tolerance  for  sugar  has  been  lowered  to 
such  an  extent  that  even  the  small  amount  of  sugar  con- 
tained in  diluted  cow's  milk  causes  trouble.  There  are  also 
theoretical  grounds  for  using  the  feeding  as  in  cases  of 
severe  fermentative  diarrhoea,  where  the  fermentative  bac- 
teria are  kept  alive  by  even  a  small  amount  of  sugar,  and 
particularly  where  the  diarrhoea  is  of  long  duration.  Certain 
cases  of  marasmus  do  well  upon  this  food,  due  to  their  lia- 
Dility  both  to  sugar  indigestion  and  to  fermentative  diarrhoea. 

Like  other  complicated  feedings,  many  elements  deter- 
mine its  usefulness,  and  there  are  probably  other  elements 
besides  the  mere  absence  of  sugar  and  salts  that  enter  into 
the  successful  use  of  protein  milk.  The  fact  that  the  curds 
have  been  coagulated  and  mechanically  separated  again  un- 
doubtedly has  something  to  do  with  the  efficacy  of  the  food. 
The  buttermilk,  containing  as  it  does  lactic  acid  bacilli,  may 
have  its  influence  on  the  intestinal  flora,  and,  finally,  the 
high  food  value  of  such  a  mixture  is  very  desirable. 

Protein  milk  is  made  in  the  following  manner :  one  quart 
of  whole  milk  is  warmed  to  blood  heat  (100°  F.).  One  tea- 
spoonful  of  liquid  rennet,  or  essence  of  pepsin,  or  a  junket 
tablet  dissolved  in  a  little  cold  water,  is  thoroughly  stirred 
into  the  warm  milk.  It  is  then  allowed  to  stand  quiety  until 
it  is  thoroughly  jellied,  which  generally  takes  from  ten  to 
twenty  minutes.  It  is  then  put  upon  the  stove  and  is  heated 
to  a  steaming  heat  (160°  F.),  being  stirred  vigorously  all  the 
time.  This  process  is  to  kill  the  pepsin  or  rennet  so  that  it 
will  not  curdle  the  buttermilk  when  added  to  it  later.  The 
curds  and  whey  now  being  separated  are  poured  into  a  fine 
wire  colander  or  sieve  and  all  the  whey  is  allowed  to  drain 
off.  The  whey  is  then  discarded  and  the  curds  pressed 
9 


130  SIMPLIFIED  INFANT  FEEDING 

through  the  wire  sieve  with  a  wooden  spoon.  These  curds 
are  very  tough  from  the  heating,  and  it  requires  consider- 
able time  and  muscular  effort  to  push  them  through  the  sieve. 
During  this  process  of  breaking  up  the  curds  cold  water 
may  be  poured  upon  them  (to  aid  in  the  process)  from  the 
pint  which  has  already  been  measured  out  for  this  purpose. 
When  the  curds  have  all  been  pushed  through  and  scraped 
off  the  bottom  of  the  sieve  the  balance  of  the  pint  of  water 
is  added  and  the  mixture  strained  through  the  sieve  at  least 
two  more  times.  To  this  pint  of  curds  and  water  is  finally 
added  one  pint  of  buttermilk,  and  the  food  is  completed. 
Buttermilk  from  the  churn  is  the  best,  but  artificial  butter- 
milk may  be  used  when  made  of  skimmed  milk,  soured  with 
the  lactic  acid  bacillus.  It  may  be  sweetened  with  saccha- 
rine, one  grain  to  the  quart  of  food,  if  on  account  of  the  taste 
it  is  not  well  taken. 

The  quantity  to  be  given  and  the  intervals  between  feed- 
ings depend  upon  the  age,  size,  and  weight  of  the  infant. 
With  the  exception  of  the  "paradoxical  weight  reaction"  to 
be  described  later,  the  more  food  given  (within  the  proper 
limits)  the  sooner  is  the  diarrhoea  improved.  In  the  author's 
opinion,  it  is  seldom  necessary  to  give  protein  milk  after  the 
diarrhoea  has  been  permanently  checked,  for  that  is  the  chief 
purpose  of  the  food.  It  is  well,  however,  to  continue  it  two 
or  three  days  after  the  stools  have  become  solid,  in  order  to 
prevent  a  recurrence.  Finkelstein  and  others  in  this  country 
have  added  sugar  to  protein  milk  and  continued  its  use  indefi- 
nitely, but  there  seems  to  be  no  necessity  for  this,  since,  once 
the  diarrhcea  is  checked,  other  foods  may  be  substituted.  It 
is  seldom  advisable  to  continue  the  food  longer  than  ten  days 
unless  sugar  is  added,  and  with  small,  young  infants  who 
are  emaciated  and  have  little  power  of  resistance  it  should 
not  be  given  for  even  so  long  a  time.  Often  within  forty-eight 
hours  the  desired  results  may  be  obtained :  the  stools  become 
dry  or  pasty,  the  mucus  disappears,  and  by  continuing  the 


131 

protein  milk  for  two  days  longer  a  recurrence  is  prevented. 

When  protein  milk  is  stopped,  boiled  milk  and  water  with- 
out sugar  should  be  given.  It  is  never  best  to  change 
abruptly  from  protein  milk  to  a  food  which  has  artificial 
sugar  added  to  it,  as  the  amount  of  lactose  already  in  the 
milk  is  sufficient  at  the  beginning.  Sugar  may  be  gradually 
added  later,  as  is  done  after  any  diarrhoea. 

After  a  little  experience,  one  learns  to  recognize  at  once ' 
these  severe  grades  of  diarrhoea  in  which  protein  milk  is 
the  food  of  choice  rather  than  the  boiled  milk  mixtures.  The 
poorly-nourished  infant  whose  feedings  have  been  fairly 
rational  or  in  whom  the  boiled  milk  feedings  have  been  used 
unsuccessfully,  or  the  infant  whose  stools  show  a  large 
amount  of  mucus  thoroughly  mixed  with  the  fecal  matter, 
should  receive  protein  milk  at  once.  Where  these  conditions 
are  not  present  the  boiled  milk  mixtures  are  usually  effective, 
especially  in  the  seasons  when  diarrhoeas  are  less  resistant 
to  treatment.  During  the  hot  summer  months  when  the 
diarrhoeas  are  severe  and  difficult  to  correct  and  infants  are 
much  more  prostrated,  protein  milk  is  practically  indispen- 
sable. In  the  author's  hands,  it  has  been  more  prompt  in 
its  action  and  saved  more  lives  than  any  other  one  food.  The 
protein  milk  is  difficult  to  make,  and  for  that  reason  is  not 
advised  in  cases  where  it  is  possible  to  clear  up  the  diar- 
rhoea with  simple  boiled  milk  and  water  mixtures. 

CASE  XXIII 

(Illustrating  the  use  of  protein  milk  in  severe  intestinal  indigestion) 
April    10:     Age,    4   months.     Birth  weight,  6  Ib. 

Present  weight,  8  Ib. 
Gain  since  birth,  2  Ib. 

General  Condition. — Emaciated,  weak,  poor  musculature;   pale,   gastro- intes- 
tinal facies;  needs  from  60  to  65  calories  per  pound  per  day. 
Stools, — For  ten  days,  eight  or  ten  green,  watery  stools,  containing  much  mucus 

and  many  curds  each  day. 
Vomiting. — Some  after  each  feeding. 
Appetite. — Ravenous. 
Sleep. — Poor;  cries  most  of  the  time. 


132  SIMPLIFIED  INFANT  FEEDING 

Temperature,  98°  F. 

Chief  Complaint. — Diarrhoea. 

Previous  Food. — During  the  first  week  of  life  an  effort  at  breast  feeding  was 
attempted  and  failed.  Top  milk  mixtures  with  lactose  were  used  for  the 
first  two  and  a  half  months  with  constant  indigestion,  diarrhoea,,  vomiting, 
and  no  gain  in  weight.  She  was  then  in  such  bad  condition  that  a  wet  nurse 
was  necessary,  and  with  this  breast  milk  she  gained  two  pounds  in  weight, 
with  a  cessation  of  her  digestive  disturbances.  She  then  weighed  eight 
pounds  and  the  wet  nurse  was  discontinued  because  of  the  loss  of  her  milk. 
Cream  and  whey  and  sugar  mixtures  were  used  for  two  weeks,  the  last  ten 
days  of  which  time  the  stools  were  as  above. 

Treatment. — Protein  milk  was  given.  4  oz.  every  3  hours,  7  feedings  in  24  hours, 

at  6,  9,  12  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

April  13  (3  days  later)  :     Weight,  7  Ib.  14  oz. 

Loss,  2  oz. 

General  Condition. — Same  as  before,  except  that  facial  expression  has  im- 
proved. 

Stools. — Three  large,  pale  green,  firm,  smooth,  homogeneous,  with  no  mucus. 
Vomiting. — None. 
Appetite. — Ravenous. 
Sleep. — Better. 
Temperature,  98°  F. 
Treatment. — Protein  milk  continued.     Same  quantity  and  intervals. 

April  16  (3  days  later)  :     Weight,  8  Ib. 

Gain,  2  oz. 

General  Condition. — As  at  last  date. 

Stools. — One  large,  hard,  dry,  crumbly,  pale  green,  no  mucus. 
Vomiting. — None. 
Appetite. — Ravenous. 
Sleep. — Poor. 

Treatment. — Food  prescribed: 

Milk 12  oz.  )       .  Divide  into  7  feedings.   Feed 

Water    24  oz.  |  boiled  5  Oz.  every  3  hours. 

Sugar    0 

Increase  the  milk  one  ounce  and  decrease  the  water  the  same  amount 
each  day  until  the  formula  is  half  milk  and  half  water. 

This  infant  had  no  return  of  the  diarrhoea  as  the  strength  of  the  milk  was 
increased  and  sugar  added,  and  at  one  year  of  age  weighed  twenty  pounds. 

The  sugar  indigestion  was  so  severe  and  the  infant  was 
so  sick  that  it  was  considered  best  to  begin  at  once  with  the 
protein  milk  instead  of  the  plain  milk  and  water.  The 


TREATMENT  OF  DIAEEHCEA  133 

bowels  were  normal  by  the  third  day.  It  is  generally  best  to 
wait  until  they  have  been  normal  for  three  or  four  days 
or  until  they  are  constipated,  as  they  were  in  this  case, 
before  changing  to  boiled  mixtures. 

PEOTEIN  MILK  IN  CASES  OF  DIAREHCEA  IN  WHICH  THE  OTHER 

METHODS  OF  TREATMENT  FAIL 

When  the  various  methods  of  treating  diarrhoea,  includ- 
ing barley  water,  boiled  milk  mixtures,  etc.,  have  been  un- 
successful and  the  diarrhoea  persists  in  unabated  severity, 
a  protein  milk  feeding  should  be  instituted  at  once. 

CASE  XXIV 

(Illustrating  the  use  of  protein  milk  in  diarrhoea  which  has  been  unrelieved 
by  other  methods) 

August  17:     Age,  10  months.     Weight,  16  Ib.  8  oz. 

General  Condition. — Fairly  well  nourished,  tall  stature,  otherwise  well  de- 
veloped. Skin  shows  some  Avrinkling  due  to  recent  loss  of  weight. 

Stools. — 'For  the  last  two  weeks  has  had  six  to  ten  stools  a  day,  green  or 
yellow,  watery,  normal  odor,  with  a  great  deal  of  mucus  and  no  curds. 

Vomiting. — None  since  onset. 

Appetite. — Poor. 

Sleep. — Extremely  restless. 

Temperature. — Some  fever  at  onset,  now  98°  F. 

Chief  Complaint. — Diarrhoea. 

Previous  Food. — Had  been  bottle-fed!  with  the  proper  milk  mixtures  until  the 
onset  of  the  diarrhoea  two  weeks  ago.  At  that  time  barley  gruel  had  been 
given  for  two  days,  after  a  dose  of  castor  oil.  Boiled  milk  and  water  mixtures 
•were  then  substituted.  A  week  ago  another  dose  of  castor  oil  had  been  given, 
followed  by  albumin-water  feedings  for  two  days.  Again  half  milk  and  half 
water  were  given,  boiled  together,  eight  ounces  every  three  hours,  six  feedings 
in  24  hours.  Since  the  stools  had  not  improved  under  this  treatment  and 
since  the  diarrhoea  was  of  such  a  severe  grade  and  long  duration,  protein  milk 
was  resorted  to. 

Treatment. — Food  prescribed : 

Protein  milk,  4  oz.  (increased  to  6  oz.  if  well  borne)  every  3  hours,  at  6,  9, 

12  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

August  21  (4  days  later)  :     Weight,  16  Ib.  3  oz. 

Loss,  5  oz. 

General  Condition. — As  at  the  last  visit. 

Stools. — Three  smooth,  pasty  stools,  light  yellow  in  color,  of  normal  consis- 
tency, with  email  amount  of  mucus. 


134  SIMPLIFIED  INFANT  FEEDING 

Vomi  ting  .  —  None. 
Appetite.  —  Extremely   hungry. 
Sleep.  —  Good  at  night. 
Temperature,  98.6°  F. 
Treatment.  —  Food  prescribed: 

Protein  milk,  8  oz.  every  3  hours,  6  feedings  in  24  hours. 

The  milk  was  0till  continued,  though  the  stools  were  fairly  normal,  be- 
cause the  mucus  had  not  entirely  disappeared  from  the  stools. 

August  25  (4  days  later)  :     Weight,  16  Ib.  6  oz. 

Gain,   3   oz. 

General  Condition.  —  As  above. 

Stools.  —  One  hard,  smooth,  pale  yellow  stool  a  day. 
Vomiting.  —  None. 
Appetite.  —  Hungry. 
Sleep.  —  Excellent. 
Temperature,  98.6°  F. 
Treatment.  —  Food  prescribed: 


16  oz.  j  Divide  into  6  feedings.    Feed  6^ 

Water   ..........  32oz'>  oz.  every  3  hours. 

Sugar    ..........     0  oz. 

Each  day  the  milk  is  to  be  increased  four  ounces  and  the  water  decreased 
the  same  amount  and  later  sugar  added  until  the  proper  amount  of  food  is 
given  to  fulfil  the  caloric  requirements. 

With  this  treatment  there  was  no  recurrence  of  diarrhoea. 

Another  instance  of  the  successful  use  of  protein  milk 
is  shown  in 

CASE  XXV 

(Also  illustrating  the  use  of  protein  milk  where  the  others  failed) 
September  16:     Age,  7%  months.     Weight,  15  Ib.  3  oz. 

General  Condition.  —  Well  nourished,  well  developed,  good  color.  Buttocks 
badly  chafed.  Needs  45  calories  per  pound  per  day. 

Stools.  —  For  one  week,  four  or  five  green  or  yellow,  watery  stools  with  a  good 
deal  of  mucus  but  no  curds  or  blood. 

Vomiting.  —  None. 

Appetite.  —  Poor;  leaves  one  or  two  ounces  at  each  feeding. 

Sleep.—  Fretful. 

Temperature,  98.6°  F. 

Chief  Complaint.  —  Diarrhoea. 

Previous  Food.  —  Has  had  the  proper  milk  and  water  mixtures  until  a  week 
ago,  when,  on  account  of  diarrhoea,  one-third,  milk  and  two-thirds  water  were 
given  for  three  days,  then  increased  to  half  milk  and  half  water,  boiled, 
without  sugar,  eight  ounces  at  a  feeding,  five  feedings  in  24  hours.  Under 


TREATMENT  OF  DIAERHCEA  135 

this    treatment    there    was    no    improvement    in    the   diarrhoea   after    one 
week's  trial. 

Treatment. — On  account  of  the  persistence  of  the  diarrhoea  with  the  boiled 
milk  feeding,  protein  milk  was  given,  five  ounces  every  three  hours,  six- 
feedings  in  24  hours. 

September   19    (3  days  later):     Weight,   15  Ib. 

Loss,  3  oz. 

General  Condition. — The  same. 
Stools. — Yesterday,  two  smooth,  hard,  yellow  stools,  without  mucus;    today 

none. 

Vomiting. — None. 

Appetite. — Refused  protein  milk  at  first;  well  taken  the  second  day. 
Sleep. — Good. 
Temperature,  98.6°  F. 
Treatment. — Food  prescribed: 

Milk     21  oz.  )  Divide  into  6   feedings   of  6   oz. 

V    nAllpo 

Water    21  oz.  j  each.    Feed  every  3  hours  at  6, 

Sugar    0  9,  12  A.M.,  3,  6,  9  P.M. 

With  these  boiled  milk  feedings  the  stools  remained  constipated  for  a  num- 
ber of  days,  so  that  milk  and  sugar  could  be  rapidly  increased  to  fulfil  the 
caloric  needs. 

PROTEIN  MILK  IN  SELECTED  CASES  OF  MARASMUS 
Marasmus  has  been  described  in  the  chapter  on  "Classi- 
fication of  Diarrhoeas."  Not  all  cases  of  marasmus  have 
diarrhoea ;  in  fact,  many  of  them  have  perfectly  normal  stools. 
In  many  cases  of  marasmus  where  there  is  diarrhoea 
protein  milk  will  be  found  useful.  Nothing,  however,  is  com- 
parable toi  breast  milk  if  it  can  be  secured  for  such  cases. 
Even  breast  milk  is  not  a  universal  panacea  for  all  cases  of 
marasmus.  It  is  not  astonishing,  then,  that  the  most  careful 
administration  of  protein  milk  or  any  other  food  is  often 
without  avail. 

Many  severe  cases  of  marasmus  show  the  "paradoxical 
weight  reaction"  of  Finkelstein;  that  is,  the  more  food 
that  is  given  them,  the  more  do  they  lose  in  weight.  This 
may  be  true  even  when  there  is  no  diarrhoea,  and  when 
the  stools  are  normal  or  even  constipated.  When  this  '  *  para- 
doxical weight  reaction"  occurs,  very  small  quantities  of 


136  SIMPLIFIED  INFANT  FEEDING 

protein  milk  should  be  used,  in  order,  if  possible,  to  raise  the 
infant's  tolerance  for  food.  It  is  sometimes  well  to  give 
only  one  ounce  of  protein  milk  every  two  hours  for  the  first 
day.  The  next  day,  one  and  a  half  or  two  ounces  are  given 
every  two  hours,  and  thereafter  the  food  increased  as  rap- 
idly as  possible,  the  weight  being  carefully  watched  and  the 
increase  in  food  regulated  by  it.  If  an  infant,  who  has  been 
gradually  losing  weight,  is  going  to  do  well  upon  this  method 
of  treatment,  it  will  be  noted  that  the  gradual  loss  of  weight 
is  stopped  when  the  food  is  cut  down  to  this  small  amount. 
There  will  be  no.  gain  in  weight  during  the  administration 
of  protein  milk,  the  most  to  be  expected  being  an  increase  in 
the  infant's  tolerance,  a  checking  of  the  diarrhoea  and  vomit- 
ing, and  a  stationary  weight.  After  these  things  have  been 
accomplished,  and  after  the  infant  can  take  from  thirty  to 
forty  ounces  of  protein  milk  in  twenty-four  hours  without  a 
loss  in  weight,  the  food  can  be  changed  to  boiled  milk  and 
water  without  sugar.  It  is  best  to  begin  with  one-third  milk 
and  two-thirds  water.  The  increase  must  be  very  gradual, 
and  the  sugar  must  not  be  added  to  the  food  too  soon. 

A  startling  phenomenon  may  occasionally  be  observed 
during  this  treatment,  as  well  'as  in  very  sick  infants  who  are 
fed  upon  a  food  containing  no  sugar  and  little  salts  over 
too  long  a  period  of  time.  The  infant  suddenly  appears  to 
go  into  collapse.  This  is  probably  from  the  gradual  and 
continuous  loss  of  body  fluids  as  a  result  of  the  prolonged 
absence  of  the  sugar  and  salts  from  the  food.  When  this 
occurs,  the  addition  of  sugar  to  the  food  in  fairly  large 
quantities  will  overcome  the  collapse,  and  the  infant  will  gain 
one-half  to  one  pound  in  weight  in  the  next  twenty-four 
hours,  due  to  water  retention  through  osmosis ;  that  is,  the 
sugar  attracts  water  and  prevents  it  from  being  excreted 
in  the  urine.  This  water  retention  will  sometimes  save  an 
infant's  life,  and  it  is  well  to  try  it  in  cases  that  go  into 
collapse  while  being  fed  a  sugar-and-salt-free  diet,  even 
though  the  sugar  is  contra-indicated  by  the  diarrhoea. 


TREATMENT  OF  DIARRHCEA  137 

CASE  XXVI 

(Illustrating  the  use  of  protein  milk  in  the  paradoxical  weight  reaction) 
September  1 :    Age,  8  months.    Weight,  9  ib. 

General  Condition. — Extreme  emaciation,  senile  facies,  skin  wrinkled  and.  in- 
elastic, abdominal  tone  poor  (doughy  feel),  apathetic,  seldom  cries,  moves 
about  very  little.  Needs  65  calories  per  pound  per  day. 

Stools. — For  an  indefinite  period,  four  large,  pale  green,  rather  loose  stools  a 
day,  with  a  large  amount  of  mucus  mixed  thoroughly  throughout  the  fecal 
matter. 

Vomiting. — None. 

Appetite. — Good. 

Temperature,  97°  F. 

Chief  Complaint. — Marasmus;  diarrhoea. 

Previous  Food. — Artificially  fed  since  birth.  There  had  been  so  many  changes 
in  the  food  that  it  is  impossible  to  record  them.  For  the  last  four  weeks 
there  had  been  a  steady  decrease  in  weight,  slow  at  first,  but  very  rapid 
during  the  last  few  days.  During  this  period  the  stools  had  been  as  above, 
and  the  infant  had  been  fed  upon  the  following  food: 

Milk    32  oz.  )  Fed  8  oz.  every  3  hours,  6  feed- 
Water    16  oz.  }•  b  ings  in  24  hours. 

Oane  sugar 2  oz. 

Treatment. — Food  prescribed: 

Protein  milk.  Feed  1  oz.  every  2  hours,  10  feed- 

ings in  24  hours. 

September  2  (1  day  later)  :     Weight,  9  Ib. 
General  Condition. — The  same. 

Stools. — Four  smaller,  pale  green,  loose,  with  less  mucus. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Excellent 
Temperature,  98.6°  F. 
Treatment. — Food  prescribed: 

Protein  milk.  Feed  2  oz.  every  2  hours,  10  feed- 

ings in  24  hours. 

September  3  ( 1  day  later )  :     Weight,  9  Ib. 
General  Condition. — The  same. 

Stools. — Three  pale  green,  firm,  smooth,  little  mucus. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Excellent. 
Temperature,  98.6°  F. 
Treatment. — Food  prescribed. 

Protein  milk.  Feed  3  oz.  every  2  hours,  10  feed- 

ings in  24  hours. 


138  SIMPLIFIED  INFANT  FEEDING 

September  5  (2  days  later) :    Weight,  9  Ib. 
General  Condition. — General  nutrition  as  before,  but  less  apathetic;   moves 

about  more  of  its  own  accord. 
Stools. — As  at  last  date. 
Vom  i  ting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 
Temperature,  98.6°  F. 
Treatment. — Food  prescribed. 

Protein  milk.  Feed  4  oz.  every  3  hours,  7  feed- 

ings in  24  hours. 

September   10    (5  days  later)  :      Weight,  9  Ib. 
General  Condition, — Less  apathetic. 

Stools. — Three  large,  soft,  homogeneous,  pale  green,  no  mucus. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 
Treatment. — Food  prescribed. 

Milk    20  oz.  >  Feed  5  oz.  every  3  hours,  7  feed- 
Water   20  oz.  J  b  ings  in  24  hours. 

Sugar    0 

September   13    (3  days  later)  :      Weight,  9   Ib. 

General  Condition. — Nutrition  better ;  much  brighter  and  more  active. 

Stools. — Two  pale  green,  smooth,  soft,  no  mucus. 

Vomiting. — None. 

Appetite. — Hungry. 

Sleep. — Fair. 

Treatment. — Food  prescribed. 

Milk    20  oz.  |  Feed  5  oz.  every  3  hours,  7  feed- 
Water    20  oz.  J  b  ings  in  24  hours. 

Cane  sugar  %  oz. 

September  17   (4  days  later)  :     Weight,  9  Ib.  5  oz. 

General  Condition. — As  at  last  date. 

Stools. — One  to  two  pale  green,  smooth,  homogeneous,  no  mucus. 

Vomiting. — None. 

Appetite. — Hungry. 

Sleep. — Fair. 

Treatment. — Food  prescribed. 

Milk 24  oz.  )  Feed  8  oz.  every  3  hours,  7  feed- 
Water    24  oz.  j  b  ings  in  24  hours. 

Cane  sugar l/2  oz. 

Upon  the  addition  of  this  small  amount  of  sugar  the  first  gain  in  weight 

occurred,  due  to  water  retention.     This  gain  in  weight  did  not  begin  until 

seventeen  days  after  the  infant  came  under  observation.     The  main  thing  in 

this  case  was  not  to  increase  the  food  too  rapidly,  lest  the  gastro-intestinal 

disturbances  should  return. 


CHAPTER  XI 

SECOND  METHOD  OF  TREATING  DIARRHCEA 

CABBOHYDBATE  DIET 

(a)  Barley  gruel  made  without  milk. 

(b)  Thick  gruels  of  various  kinds,  such  as  cornstarch, 

arrowroot,  etc.,  fed  with  spoon.     Breadstuffs. 

(c)  The  gruels  cooked  with  part  fat-free  milk. 

Indications. — (1)  Putrefactive  diarrho3a;  (2)  most  infec- 
tive diarrhoeas  occurring  in  infants  six  months  of  age  or 
over;  (3)  chronic  diarrho3as  in  older  children;  (4)  infants 
over  six  months  of  age  who  are  not  improved  after  a  thor- 
ough trial  of  the  protein  diet. 

Theoretically,  any  carbohydrate  will  do,  and  some  inves- 
tigators believe  that  sugar,  particularly  lactose,  is  the  best 
form  of  carbohydrate  to  use.  The  author  differs  with  this 
opinion,  however,  for  three  reasons:  First,  with  younger 
infants  there  may  have  been  a  previous  sugar  intolerance, 
and  sugar  indigestion  may  be  started  up  in  this  way.  Second, 
it  is  undoubtedly  better  to  increase  the  sugars  later,  after 
the  milk  mixtures  have  been  begun.  Third,  the  reasons 
given  in  favor  of  lactose  being  the  proper  carbohydrate 
for  infants  are  theoretical  and  are  not  supported  by  clini- 
cal evidence. 

For  small  infants  under  four  months  of  age  the  barley 
gruel  should  be  made  weak,  one  level  tablespoonful  to  the 
quart  of  water.  For  the  average-sized  infant,  over  four 
months  of  age,  two  or  three  level  tablespoonfuls  of  the  flour 
to  one  quart  of  water  may  be  used,  and  for  still  older  infants, 
eight  or  nine  months  of  age,  four  or  five  tablespoonfuls  to 
the  quart.  Use  barley  flour,  which  can  be  bought  at  any 
drug  store,  either  Robinson's,  Brooks'  or  the  Cereo  Barley. 

139 


140  SIMPLIFIED  INFANT  FEEDING 

Ordinary  pearl  barley  can  be  used  but  it  requires  at 
least  three  hours  cooking  instead  of  the  twenty  minutes 
stated  below. 

Take  the  amount  of  barley  stated  above  and  gradually 
stir  into  it  enough  cold  water  to  make  a  thin  paste,  mixing 
it  until  there  are  no  lumps.  Measure  out  the  amount  of  water 
stated  above,  put  it  on  the  stove  in  a  saucepan  and  when  it 
has  begun  to  boil,  slowly  add  the  paste  to  it,  stirring  it  until 
it  has  come  to  a  boil  again.  Add  ^4  teaspoonful  of  table 
salt  and  let  it  boil  slowly  (simmer)  for  twenty  minutes. 
Strain  and  add  enough  water  to  it  (if  necessary)  to  make  the 
required  number  of  ounces  of  barley.  The  gruel  should  be 
salted  to  taste,  but  no  sugar  or  milk  or  any  other  ingredient 
should  be  added  to  it.  It  should  be  given  in  the  quantity 
and  at  the  intervals  suitable  for  the  infant's  age  and  size 
(see  page  62).  Since  the  infant  is  apt  to  be  very  hungry 
at  this  stage,  it  may  be  given,  every  two  hours  to  appease 
the  appetite,  provided  there  is  no  vomiting.  Often  it  is  not 
necessary  to  use  the  barley  longer  than  twenty-four  hours, 
and  it  should  never  be  used  without  the  addition  of  milk 
longer  than  forty-eight  hours  in  small  or  weak  infants  under 
four  months  of  age.  The  older  and  stronger  the  infant,  the 
longer  an  exclusive  gruel  diet  may  be  safely  continued, 
because  sufficient  starch  may  be  given  to  maintain  the  nutri- 
tion. An  exclusive  gruel  diet  without  the  addition  of  milk 
should  never  be  used  longer  than  four  days  in  infants  under 
one  year  of  age,  even  when  the  infant  is  well  nourished.  If  it 
is  considered  desirable  to  continue  the  carbohydrate  diet 
longer  than  this  the  gruels  should  be  made  with  part  fat-free 
rnilk.  In  this  case  equal  parts  of  fat-free  milk  and  water  are 
brought  to  the  boiling  point  and  the  desired  quantity  of 
flour  is  added  and  cooked  like  the  plain  barley  gruel 
described  above. 

For  infants  old  enough  to  be  fed  with  a  spoon,  thick 
gruels  are  well  taken  and  are  effective  in  checking  the  diar- 


TREATMENT  OF  DIABBHCEA  141 

rhcea.  A  large  variety  is  desirable  to  avoid  monotony  and 
often  certain  ones  will  be  eaten  with  relish  while  others 
are  refused. 

Any  of  the  following  gruels  may  be  given  and  should  be 
made  in  the  same  way  as  barley  gruel :  Cornstarch,  Arrow- 
root, Bice  Flour  (or  Bice  strained  through  a  very  fine 
strainer),  Imperial  Granum  or  Browned  Flour  Gruel.  To 
make  Browned  Flour  Gruel  ordinary  wheat  flour  should  be 
browned  in  the  oven,  being  careful  to  use  a  plate  or  baking 
pan  that  has  never  had  grease  upon  it. 

Besides  the  various  gruels  white  bread  (without  butter), 
sliced  thin  and  toasted  brown  and  hard  in  the  oven,  may  be 
given,  or  very  stale  white  bread  which  is  cut  in  slices  and 
allowed  to  dry  for  a  day  or  two.  A  bread  pap  can  be  made 
of  either  of  these,  by  moistening  the  toast  or  stale  bread  with 
boiling  water  and  putting  it  on  the  stove  to  cook  a  moment. 
It  may  be  made  thick  or  thin  according  to  the  child 's  prefer- 
ence. The  following  crackers  may  be  given:  Arrowroot 
crackers,  Uneeda  biscuit,  Zweiback.  Nothing  whatever  that 
is  not  on  this  list  is  to  be  given.  Boiled  water,  cold  or  warm, 
may  be  given  in  plenty.  , 

As  soon  as  the  stools  have  become  brown  in  color  and 
firmer  in  consistency,  the  milk  may  be  gradually  added  and 
the  food  increased  sufficiently  to  supply  the  infant's  nutri- 
tional needs.  If,  as  occasionally  happens,  in  a  severe  grade 
of  diarrhoea  during  the  summer  months,  the  stools  show 
mucus  and  other  signs  of  indigestion  after  the  milk  has 
been  given,  the  barley  gruel  may  again  be  given  for  twenty- 
four  to  forty-eight  hours.  It  is  never  advisable  to  try  it  a 
third  time,  nor  is  it  often  necessary. 

INDICATIONS  FOB  THE  USE  OF  THE  SECOND  METHOD 

Putrefactive  diarrhoea  is  seldom  seen  in  very  young  in- 
fants, except  in  cases  where  the  infant  has  been  fed  upon 
a  sugar-free  diet  or  a  diet  very  low  in  sugar.  Older  infants 
who  receive  a  larger  amount  of  milk  and  less  sugar  in  the 


142  SIMPLIFIED  INFANT  FEEDING 

food,  or  who  are  getting  a  mixed  diet,  are  more  liable  to 
putrefactive  diarrhoea. 

This  method  is  also  indicated  in  cases  that  have  been 
changed  from  the  fermentative  type  to  the  putrefactive  type 
of  diarrhoea  by  omitting  the  sugar.  It  is  to  be  used  in  large, 
well-nourished  infants  over  six  months  of  age  that  have 
not  responded  to  the  first  method  of  treatment  on  the 
dhanoe  that  the  diarrhoea  is  putrefactive,  even  though  the 
stools  do  not  have  a  putrefactive  odor.  In  other  words,  it 
may  be  used  as  a  therapeutic  test  to  discover  the  variety 
of  the  diarrhoea. 

CASE  XXVII 

("Illustrating  the  use  of  the  second  method  in  putrefactive  diarrhoea) 
August  27:     Age,  8  months.     Weight,  13  Ib.  13  oz. 

General  Condition. — Poorly  nourished,  pale,  fair  musculature. 

Stools-. — For  one  week,  four  or  five  loose,  foul-smelling,  moist  stools,  with  much 

mucus,  no  curds. 
Vomiting. — None. 
Appetite. — Ravenous. 
Sleep. — Fair. 
Temperature,  100.5°  F. 
Chief  Complaint. — Diarrhoea. 

Previous  Food: 

Equal  parts  of  barley,  milk  and  water,  one  lump  of  sugar  to  8  ounces  of  food, 
had  been  the  mixture  used. 

Treatment. — Food  prescribed : 

Barley  gruel,  4  tablespoonfuls  to      Feed  every  3  hours,  6  feedings  in  24 
the  quart,  given  in  the  bottle          hours,  at  6,  9,  12  A.M.,  3,  6,  9  P.M. 
and  the  various  thick  gruels  fed 
with  the  spoon. 

August  30    (3  days  later):     Weight,  13  Ib.  4  oz. 

Loss,  9  oz. 

General  Condition. — The  same. 

Stools. — Two  brown,  smooth,  soft,  homogeneous;  no  mucus  or  curds. 

Vomiting. — None. 

Appetite. — Ravenous. 

Sleep. — Good. 

Temperature,  98°  F. 


143 

Treatment. — Food  prescribed : 

Fat-free  milk   24  oz.  )  Divide     into     6     feedings. 

Water 24  oz.  j  b  Feed  8  oz.  every  3  hours, 

Barley    4  tablespoonfuls          at  6,  9,  12  A.M.,  3,  6,  9 

Sugar 0  P.M. 

Thick  gruels  made  with  half  fat-free  milk  fed  with  a  spoon. 
September  3  (4  days  later) :     Weight,  13  Ib.  4  oz. 

No  gain  or  loss. 
General  Condition. — The  same. 

Stools. — Constipated,  one    (with  enema)    smooth,  hard,  homogeneous. 
Vomi  ting. — None. 
Appetite. — Ravenous. 
Sleep. — Fair. 

Treatment. — Food  given: 

Fat-free  milk  28  oz.  )  Divide  and  feed  as  before. 

Water 20  oz.  [  boiled 

Barley    4  tablespoonfuls 

Cane  sugar Y2  oz. 

There  was  no  return  of  the  diarrhoea  when  the  sugar  was  gradually 
increased  up  to  1%  ounces  in  the  twenty-four-hour  amount. 

This  infant  was  very  much  undernourished,  weighing  less  than  14  pounds 
at  eight  months  of  age.  At  the  time  of  the  first  visit  the  stools  were  loose  and 
foul-smelling,  showing  that  the  diarrhoea  had  changed  to  the  putrefactive 
type.  Gruels  were  then  given,  and  four  days  later  the  stools  were  normal — 
in  fact,  this  diet  caused  constipation.  For  the  constipation)  the  mother  was 
cautioned  against  giving  a  cathartic.  If  special  care  is  not  taken  to  give 
such  instructions,  a  mother's  fear  of  constipation  will  generally  lead  her  to 
give  a  dose  of  castor  oil,  starting  up  the  diarrhoea  again,  as  the  bowels  are 
etill  in  an  irritable  condition. 

Overfeeding,  when  it  occurs  in  older,  weft-nourished 
infants,  may  be  treated  by  either  the  first  or  second  method. 
Provided  there  is  not  a  fermentative  diarrhoea,  a  diet  of  weak 
barley  gruel  does  no  harm  to  them  as  it  does  to  smaller, 
weaker  babies,  and  the  rest  given  to  the  digestive  apparatus 
by  a  gruel  diet  is  often  effective.  A  cathartic  should  not 

be  administered. 

CASE  XXVIII 

(Illustrating  the  use  of  the  second  method  in  overfeeding) 

June  29:     Age,  8  months.     Weight,  19  Ib. 

General  Condition. — Fat,  good  color,  somewhat  rhachitic,  good  musculature. 
Stools. — For  four  days,  three  or  four  large,  yellow,  watery,  with  much  mucus, 
no  curds. 


144 


Vomiting. — None. 

Appetite. — Leaves  two  or  three  ounces  several  times  a  day. 

8  leep. — Restless. 

Temperature,  98.6°  F. 

Chief  Complaint. — Diarrhoea. 


Milk   .  .   38       oz.  )  (760  cals.)         Feed  8%  oz.  every  3  hours,  6 

boiled 


Previous  Food: 

z.   ) 

Barley  gruel.  14      oz.   f  (50  cals.)  feedings  in  24  hours. 

Cane  sugar..     2%  oz.  (300  cals.) 

1110  cals.,  or  58  per  pound;  the  caloric  requirements  of  this  fat  baby  would 
be  only  40  to  45  per  pound. 

Treatment. — Food  prescribed : 

Barley  gruel :  2  tablespoonfuls  ( %  oz. )  to  the  quart.    Feed  8  oz.  every  3  hours. 

June  30  (1  day  later)  :  Weight,  18  Ib.  12  oz. 

Loss,  4  oz. 

General  Condition. — The  same. 

Stools. — Three  smooth,  soft,  brown  stools,  with  no  mucus  or  curds. 
Vomiting. — None. 
A  ppeti  te. — Hungry. 

Sleep. — Good  at  night,  restless  during  the  day. 
Temperature,  98.6°  F. 

Treatment. — Food  prescribed : 

Milk 24  oz.  )       .          ( 480  cals. )       Divide  into  6  feedings  of  8  oz.  each 

Water 24  oz.  [  Feed  every  3  hours  at  6,  9.  12 

Sugar 0  A.M.,  3,  6,  9  P.M. 

480  calories,  or  about  25  per  pound. 

July  5    (5  days  later)  :     Weight,  18  Ib.  14  oz. 

Gain,  2  oz. 

General  Condition. — The  same. 
Stools. — One  large,  light  yellow,  smooth,  soft. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 

Treatment. — Food  prescribed: 

Milk    24  oz. )  (480  cals.)        Given  in  same  quantities   and  at 

Water   ....   24  oz.  j  same  intervals  as  before. 

Sugar    . .  . .    %  oz.  (60  cals. ) 

540  calories,  or  28  per  pound. 

As  the  sugar  and  milk  were  increased  to  the  quantity  required  to  fulfil 
the  caloric  needs,  a  normal  gain  in  weight  was  made  and  the  stools 
remained  normal. 


TREATMENT  OF  DIAEBHCEA  145 

Diarrhoea  of  long  standing,  sometimes  called  chronic 
•diarrhoea,  is  effectively  treated  with  a  carbohydrate  diet 
combined  with  fat-free  milk.  Every  year  a  large  number  of 
infants  are  seen  whose  stools  have  been  loose  during  the 
whole  summer  and  who  have  become  emaciated,  anaemic  and 
«ven  rhachitic  from  the  inability  to  digest  their  food.  Not 
only  does  the  pure  carbohydrate  and  the  fat-free  diet  stop 
the  diarrhoea  but  it  makes  it  possible  to  put  on  weight  with 
remarkable  rapidity. 

CASE  XXIX 

(Illustrating  gruel  and  fat-free  diet) 

January  3:     Age,  7  months.     Weight,   15  Ib.  8  oz. 

-General  Condition. — Pale,  emaciated,  ribs  all  showing  (size  of  six-months-old 

baby),  delicate  facies,  considerable  abdominal  distention. 
Stools. — For  three  months,  two  to  five  loose,  watery,  yellow  stools  a  day  with 

much  mucus  and  often  considerable  tenesmus. 
Vomiting. — None. 

Appetite. — Ravenously  hungry  all  the  time. 
Sleep. — Good. 
Temperature,  98.6°  F. 
•Chief  Complaint. — Diarrhoea,  emaciation. 

Previous  Food: 

"Milk    (unboiled)     ....   4  oz. 

Barley    8  oz. 

Sugar    none 

Cereal  was  given  once  a  day;  meat  broth,  spaghetti  and  bread  once  a  day. 
Four  bottles  of  the  formula  were  given  a  dav,  at  intervals  of  three  hours. 

9 

Treatment.- — Food  prescribed: 

6  A.M. — Eight  ounces  of  barley  gruel  made  of  half  fat-free  milk. 
10   A.M. — Imperial   Granum,   cornstarch   or  browned   flour   gruel   made  thick 
enough  to  eat  with  a  spoon  and  made  with  half  fat- free  milk ; 
Arrowroot  crackers,  zweiback  or  Uneeda  biscuits. 
2  P.M. — Same  as  at  10  A.M. 

6  P.M. — Bread  pat;   barley  gruel  made  with  fat-free  milk,  thin  enough  to 
drink  from  a  cup;  Arrowroot  crackers. 
January  7    (4  days  later)  :     Weight,  16  Ib.  8  oz. 

Gain,  1  Ib. 

General  Condition. — Slightly  improved. 
Stools. — Two  normal,  firm  stools  a  day. 
Vomiting . — None. 

10 


146  SIMPLIFIED  INFANT  FEEDING 

Appetite, — Hungry;  has  taken    very  large  quantities  of  gruel,  often  to  fifteen 

ounces  at  a  feeding. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Same  as  at  last  date,  except  that  four  ounces  of  fat-free  milk,  which  has 
been  boiled  three  minutes,  is  given  from  a  cup  at  each  meal,  in  addition  to  the 
above  prescribed  food  or  in  place  of  the  thin  barley  gruel. 

January  15   (7  days  later):     Weight,  17  Ib    6  oz. 

Gain,  14  oz. 

General  Condition. — Much  improved. 

X tools. — Three  firm,  normal  stools. 

Vom  i  ting. — None 

Appetite. — Excellent,  still  takes  large  quantities  of  food. 

Sleep. — Good. 

Treatment. — Food  prescribed: 

Same  as  at  last  date,  except  that  a  total  of  one  and  one-half  quarts  of  fat- 
free  milk  is  allowed  each  day,  including  that  in  which  the  gruels  are  cooked. 
January  22   (7  days  later)  :     Weight,  18  Ib.  6  oz. 

Gain,  1  Ib. 

General  Condition. — Improved. 
Stools. — Still  normal. 
Vomiting. — None. 
Appetite. — Excellent. 
Sleep. — Good. 

On  February  20th  this  baby  weighed  twenty-one  pounds  eight  ounces,  gain- 
ing six  pounds  in  about  six  weeks.  There  was  no  return  of  diarrhoea  when 
baked  potato  and  vegetables  were  added  for  their  minerals  as  well  as  for  their 
nutritive  value. 


THIRD  METHOD  OF  TREATING  DIARRHOEA 

(a)  A  cathartic,  followed  by  which  is  then  followed 

(b)  Twenty-four    hours    of  by 

starvation,  with  plain,      (c)  A  gruel  or  starch  diet. 

unsweetened      water, 

Indications.— (1)  Mild  types  of  infectious  diarrhoea;  (2) 
dysentery;  (3)  cholera  infantum;  (4)  sugar  intoxication; 
(5)  mechanical  diarrhoea. 

(1)  Mild  types  of  infectious  diarrhoea  are  more  common 
than  severe  cases,  and  are  usually  caused  by  bad  milk  or 
some  contaminated  food.  They  have  a  sudden  onset, 
attended  usually  with  vomiting  and  intestinal  pain,  though 
one  or  both  of  the  last  two  symptoms  may  be  lacking.  They 
may  occur  in  infants  who  are  doing  well  or  in  those  who  have 
been  suffering  from  intestinal  or  gastric  indigestion.  At 
the  onset  it  is  impossible  to  tell  whether  a  mild  or  severe 
case  is  commencing,  since  those  diarrhoeas  that  are  most 
easily  overcome  often  begin  with  high  temperature,  a  toxic 
appearance  of  the  baby,  and  all  the  symptoms  of  intoxication. 
The  stools  are  usually  very  numerous,  from  four  to  twelve 
in  twenty-four  hours,  and,  as  a  general  rule,  the  fewer  the 
stools  at  the  onset,  the  milder  the  diarrhoea.  This,  however, 
is  not  true  in  certain  extremely  toxic  babies  whose  bowels 
do  not  move  at  all  or  only  very  slightly  because  of  paralysis 
of  the  intestines  due  to  the  toxemia.  The  stools  are  usually 
green  and  watery — sometimes  frothy,  due  to  gas — and  con- 
tain mucus,  curds,  and  undigested  food.  They  may  be  foul, 
sour,  or  odorless,  and  are  more  usually  acid  than  alkali. 
Blood  is  never  present.  In  previously  healthy  children  such 
an  attack  is  usually  of  brief  duration — if  the  cause  is  located 

147 


148  SIMPLIFIED  INFANT  FEEDING 

and  proper  treatment  instituted.  In  more  delicate  infants, 
while  the  attack  itself  is  not  serious,  it  is  apt  to  pave  the 
way  for  more  dangerous  intestinal  disturbances. 

A  cathartic  should  be  given  at  once,  followed  by  a  com- 
plete rest  from  food,  allowing  nothing  by  mouth  except 
water  for  from  twelve  to  twenty-four  hours.  After  that, 
barley  gruel  may  be  given  for  a  day  or  two,  and  then  milk 
and  water  feedings  begun  after  the  bowels  have  cleared 
up  entirely. 

CASE  XXX 
(Illustrating  the  use  of  the  third  method  in  a  mild  type  of  infectious  diarrhoea) 

August  8:     Age,  7  months.     Weight,  15  Ib.  7  oz. 
General  Condition. — Fairly  well  nourished,  high  color,  febrile  appearance;  looks 

rather  sick. 
Stools. — In  the  last  twelve  hours  has  had  four  loose,  watery,  green  stools,  with 

much  mucus  and  some  curds. 
Vomiting. — Once  or  twice  at  the  onset. 
Appetite. — Refuses  food. 
Sleep. — Drowsy. 
Temperature,  101°  F. 
Chief  Complaint. — Diarrhoea,  with  sudden  onset. 

^Previous  Food: 

Milk 28       oz.   (560  cals.)  }  Fed  8  oz.  every  3  hours,  6  feed- 
Water 20  oz.                            ;  u  ings  in  24  hours. 

Cane  sugar.      ly2  oz.   (180  cals.) 

740  calories,  or  48-  calories  per  pound. 

Treatment. — Two  teaspoonfuls  of  castor  oil.     Nothing  else  by  mouth  except 
,     water  for  twelve  hours,  then 
Barley  gruel . .    1     tablespoonful     ( 14      Give  5  oz.  every  3  hours,  6  or  7  f  eed- 

oz. )  to  the  quart  ings  in  24  hours. 

August  9  (1  day  later)  : 
General  Condition. — Improved. 
Stools. — After  castor  oil,  three  green,  watery,  foul-smelling  stools,  with  much 

mucus.    To-day,  two  brown,  smooth,  watery  movements. 
Vomiting. — None. 
Appetite.— Takes  all  the  barley. 
Sleep. — Good. 
Temperature,  98°  F. 


TEEATMENT  OF  DIAERHCEA  149 

Treatment. — Food  prescribed : 

Milk 16  oz.  1       .  Divide  into  6  feedings.    Feed  8  oz. 

Water 32  oz.  j  every  3  hours,  at  6,  9,  12  A.M. 

Sugar 0  and  3,  6,  9  P.M. 

320  calories,  or  16  per  pound. 

August  11   {2  days  later)  : 
General   Condition. — The  same. 
Stools. — Three  yesterday,  one  to-day.     Normal. 
Vomiting. — None. 
Appetite. — Ravenous. 
Sleep. — Good  at  night,  restless  during  the  day. 

Treatment . — Food  prescribed : 

Milk 24  oz.  )       ,  Fed  in  similar  quantities  and  in- 

Water 24  oz.  C  tervals  as  above. 

Sugar 0 

480  calories,  or  25-  calories  per  pound. 

Subsequently  there  was  no  recurrence  of  diarrhoea  or  fever,  and  a  normal 
progress  was  made  as  the  food  was  increased  in  strength  and  sugar  gradually 
added. 

(2)  Dysentery. — The  physician  is  familiar  with  these 
forms  of  severe,  acute,  bloody  diarrhoea  which  occur  sud- 
denly in  an  infant  who  has  been  previously  well,  or  in  an 
infant  who  has  been  suffering  from  gastric  or  intestinal 
indigestion.  The  microorganisms  (Shiga's  dysentery  bacil- 
lus, Flexner's  dysentery  bacillus,  typhoid,  streptococci,  and 
probably  other  varieties  of  bacteria)  are  taken  in  through 
the  mouth,  usually  in  bad  milk.  Water  may  be  a  possible 
source  of  infection,  and  flies,  unclean  vessels,  nipples,  bottles, 
and  baby  "comforts"  most  certainly  are. 

The  infant  is  suddenly  overwhelmed  and  prostrated  with 
a  severe  infection.  There  is  high  temperature,  104°  to  106° 
F.,  usually  severe  vomiting  and  numerous  loose  stools,  com- 
posed chiefly  of  mucus  and  blood,  after  the  fecal  matter 
already  in  the  intestines  has  been  evacuated. 

A  cathartic  should  be  given  only  at  the  very  beginning 
of  the  diarrhoea.  Whether  the  diarrhoea  has  progressed  so 
far  as  to  render  it  inadvisable  to  give  a  cathartic,  depends 


150 

much  upon  the  presence  of  undigested  food  in  the  stools 
and  upon  the  number  of  stools  that  have  occurred  since  the 
onset.  If  there  is  no  fecal  matter  in  the  stools  and  if  there 
have  already  been  ten  or  twelve  stools,  and  if  no  food  has 
been  taken  into  the  stomach  since  the  onset,  a  cathartic  is 
not  needed. 

Plain,  unsweetened  water  only  is  given  for  the  first 
twenty-four  hours,  or  longer  if  the  vomiting  has  not  been 
checked  (see  "Vomiting,'*  p.  184).  This  treatment  is  ad- 
visable for  two  reasons :  First,  because  of  the  absolute  rest 
given  to  the  intensely  inflamed  gastro-intestinal  tract;  and, 
second,  food  of  any  sort  may  act  as  a  culture  media  for  the 
bacteria.  In  severe  cases,  where  the  body  fluids  are  being 
drained  rapidly  through  vomiting  and  frequent  evacuations, 
it  becomes  necessary  to  inject  a  normal  saline  solution  under 
the  skin  (hypodermoclysis)  or  directly  into  the  veins  (see 
4 '  Cholera  Inf  antum, ' '  p.  154) . 

After  the  twenty-four  hours  of  plain  water,  a  carbohy- 
drate is  given  in  the  form  of  a  weak  barley  gruel,  upon  the 
theory  that  some  of  the  microorganisms  in  the  intestines  are 
thus  changed  to  a  fermentative  type.  Fermentative  bacteria 
prevent  the  formation  of  toxins  and  produce  acids  which 
are  unfavorable  to  the  growth  of  the  dysentery  bacillus. 

The  barley  gruel  may  be  continued  for  three  or  four  days 
if  the  infant  is  strong  enough  to  stand  the  underfeeding 
which  it  entails.  Older  infants  (over  nine  months  of  age), 
if  they  have  been  well  nourished  formerly,  may  subsist  upon 
a  carbohydrate  diet  for  a  longer  period.  Younger  infants 
cannot  do  so  without  an  excessive  loss  in  weight,  but  in  spite 
of  this  fact,  they  must  not  be  allowed  any  food  except  barley 
gruel  for  three  or  four  days  or  until  the  blood  has  disap- 
peared from  the  stools.  Severe  cases  of  dysentery  occur- 
ring in  infants  over  nine  months  of  age  are  best  treated  with 
a  varied  starch  diet,  after  the  initial  period  of  starvation, 
giving  as  much  starch  as  the  infant  will  take.  Browned 


TREATMENT  OF  DIARRHOEA  151 

flour  gruel,  corn-starch  gruel,  farina,  arrowroot,  and  rice- 
flour  gruel  all  may  be  given.  Unsweetened  zweiback,  plain 
crackers  or  toast,  without  butter  or  milk,  and  bread  pap  are 
very  useful  and  often  gratefully  taken.  Bread  pap  may  be 
made  in  the  following  manner :  Stale  bread  is  put  into  the 
oven  and  thoroughly  browned  all  the  way  through.  It  is 
then  moistened  with  hot  water,  salted  a  little,  stirred,  and 
put  upon  the  stove  to  cook  for  a  few  minutes.  The  amount 
of  water  necessary  to  soften  it  varies  according  to  the  taste 
of  the  infant.  Most  infants  like  it  fairly  dry.  When  the 
stools  have  become  normal,  milk  may  be  gradually  added 
to  the  diet. 

Small  infants  that  cannot  be  nourished  with  an  exclusive 
starch  diet  for  more  than  three  or  four  days,  or  a  week  at 
most,  and  older  infants  and  children  who  are  losing  weight 
and  strength  too  rapidly  upon  the  starch  diet,  should  be 
given  a  food  that  is  more  nourishing.  Protein  milk  (see 
p.  128)  is  the  safest  food  to  use  under  such  circumstances, 
and  often  proves  to  be  a  valuable  aid  at  this  stage  of  the  dis- 
ease,— that  is,  when  the  blood  is  disappearing  from  the  stools 
and  the  temperature  is  lower  (101°  F.),  although  the  stools 
still  remain  loose  and  numerous  and  the  strength  is  low. 

The  following  case  is  one  of  a  moderately  severe  dysen- 
tery, the  fever  lasting  for  nearly  a  week : 

CASE  XXXI 

(Illustrating  the  use  of  the  third   method   in   a   case   of  moderately   severe 
dysentery) 

August  15:     Age,  10  months.     Weight,  20  Ib. 

General  Condition. — Well  nourished  and  developed,  looks  sick  and  toxic. 
Stools. — For  fourteen  hours,  fifteen  to  twenty  loose,  for  the  last  two  or  three 

hours  chiefly  composed  of  mucus  and  blood,  no  curds  or  fecal  matter. 
Vomiting. — Every  few  minutes  since  onset  of  diarrhoea. 
Appetite. — Thirsty;  has  had  water  and  no  food. 
Sleep. — None  since  onset. 
Temperature,  104.5°  F. 
Chief  Complaint. — Diarrhoea. 


•an 
—i  ~i 
152  SIMPLIFIED  INFANT  FEEDING 

Previous  Food. — This  infant  was  bottle-fed  and  had  done  well  since  two  months 
of  age  on  proper  milk  mixtures.  At  the  time  of  this  illness  he  was  at  a 
summer  resort  where  the  milk  supply  was  not  good,  the  milk  being  allowed 
to  stand  in  cans  before  bottling  for  distribution. 

Treatment. — No  cathartic  was  given.  One-half  teaspoonful  of  sodium  bicar- 
bonate was  added  to  eight  ounces  of  water.  Every  fifteen  or  twenty  minutes, 
one-half  ounce  of  this  was  allowed  until  the  vomiting  subsided.  After  this,^ 
plain  water  was  given  ad  libitum. 

August  16  (1  day  later)  : 

General  Condition. — Still  looks  sick  and  toxic. 
Stools. — Ten  to  fifteen  loose,  chiefly  composed  of  mucus  and  blood. 
Vomiting. — None  for  six  hours ;  retains  four  ounces  of  water  at  a  time. 
Appetite. — Thirst  quenched.    Has  been  offered  nothing  but  water. 
Sleep. — Little. 
Temperature,  102°  to  103°  F. 

Treatment : 

Feed  2  oz.  every  2  hours,  increasing 

Barley  gruel 1  tablespoonf ul  ( y4         the  amount  1  oz.  at  each  feeding  to 

oz.)  to  the  quart.  8  oz.  every  2  hours  if  there  is  no 

vomiting. 

August  17  (1  day  later)  : 
General  Condition. — Much  better. 
Stools. — Four,  thicker  in  consistency,  brown,  with  a  good  deal  of  mucus  and 

blood. 

Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Fair. 
Temperature,  99°  to  101°  F. 

Treatment. — Food  prescribed : 

Gruels  were  varied  with  brown  flour,  corn-starch, 

farina,  and  arrowroot.    Bread  pap,  dried  zwie-     Feed    everv    2    nours'    anv 
back,  and  toast  were  allowed  if  desired.  quantity  desired. 

August  21  (4  days  later) : 
General  Condition. — Good. 
Stools. — Two  brown,  soft;  no  blood  or  mucus. 
Vomiting. — None. 

Appetite. — Good;  likes  bread  pap  best. 
Sleep. — Good. 
Temperature,  98.6°  F. 

This  infant  made  an  uninterrupted  recovery  one  week  from  the  onset  of  a 
severe  diarrhcea.  The  stools  were  normal,  and  milk  was  gradually  added  to 
the  starch  diet.  Under  the  old  plan  of  treatment,  a  diarrhoea  of  this  sort  would 


FIG.  6.—  Irrigating  the  bowel. 


TREATMENT  OF  DIAERHCEA  153 

often  continue  for  three,  four,  or  even  six  weeks.  The  infant  was  old  enough, 
to  take  some  solid  food.  The  nutrition,  therefore,  did  not  suffer  as  much  as 
it  would  have  otherwise.  It  was  also  old  enough  to  utilize  the  starch.  Younger 
infants  who  have  to  be  fed  gruels  from  the  bottle  cannot  be  expected  to  respond 
so  rapidly. 

In  some  very  severe  cases,  in  spite  of  all  treatment,  the 
patient  succumbs  to  the  disease  either  during  the  first  few 
days  of  the  illness  or  after  two,  three,  or  even  four  weeks, 
when  the  infection  and  lack  of  assimilation  have  proved  too 
much  for  the  infant's  powers  of  resistance. 

Again,  cases  of  moderate  severity  are  seen  where  the 
blood  disappears  from  the  stools  in  a  day  or  two  and  the 
temperature  subsides  within  from  twenty-four  to  forty- 
eight  hours. 

CASE  XXXII 
(Illustrating  the  use  of  the  third  method  in  a  mild  case  of  infectious  diarrhoea) 

October  4:     Age,  1  year.     Weight,  21  Ib. 
General  Condition. — Fat,   excellent  color,  well   developed,   febrile  appearance. 

Looks  sick. 
Stools. — For  the  last  eight  hours,  stools  every  half  hour,  that  are  brown  and 

contain  some  fecal  matter,  though  largely  composed  of  mucus  and  a  good  deal 

of  blood. 

Vomiting. — Once  or  twice  at  onset. 

Appetite. — Will  take  nothing  but  water,  which  is  retained. 
Sleep. — Xone  to-day. 
Temperature,  104°  F. 
Chief  Complaint. — Bloody  diarrhoea. 
Previous  Food. — Whole  milk  and  cereals. 
Treatment. — One-half  ounce  castor  oil  had  been  given  and  retained  at  onset* 

Nothing  but  water  was  to  be  given  by  mouth  until  the  next  visit. 

October  5  ( 1  day  later )  : 
General  Condition. — Looks  much  better. 

Stools. — Six  in  last  twelve  hours,  pure  mucus  with  some  blood  in  each. 
Vomiting. — None. 

Appetite. — Has  taken  water  freely. 
Sleep. — Fairly  good  through  the  night. 
Temperature,  98.6°  F. 

Treatment. — Food  prescribed: 

Various  gruels,  varying  with  browned  flour,  barley,  arrowroot  and  corn- 
starch,  bread  pap,  dried  toast,  unsweetened  crackers;  plenty  of  water.  To  be 
fed  every  three  hours.  Medication:  Dilute  hydrochloric  acid,  3  drops  after 
each  feeding 


154  SIMPLIFIED  INFANT  FEEDING 

October  9  (4  days  later) : 
General  Condition. — The  same. 
Stools. — Three  soft,  brown  stools  with  no  mucus. 
Vomiting. — None. 
Appetite. — Extremely  hungry. 
Sleep. — Good  at  night. 
Temperature,  98.6°  F. 

Treatment. — Food  prescribed. 

Carbohydrate  diet  as  above,  the  gruels  being  made  of  skimmed  milk  and 
water,  half  and  half,  boiled  together,  giving  eight  ounces  at  a  feeding,  three 
times  during  the  day,  in  place  of  the  gruel. 

The  skimmed  milk  was  gradually  increased  in  quantity  and  the  full  milk 
given  after  three  days.  There  was  no  return  of  the  diarrhoea. 

(3)  Cholera  Infantum. — As  has  been  said,  it  is  doubtful 
whether  cholera  infantum  should  be  classified  as  a  separate 
form  of  infectious  diarrhoea,  as  no  bacteria  have  been  dis- 
covered as  its  direct  cause.  Clinically,  the  cases  called 
cholera  infantum  have  a  very  definite  symptomatology,  dif- 
fering from  dysentery  and  the  bloody  diarrhoeas.  These 
symptoms  are  sudden  onset,  high  rise  in  temperature,  almost 
continuous  vomiting,  profuse  diarrhusa,  stools  which  lose 
their  fecal  character  and  are  white  in  color  like  rice  water, 
consisting  almost  entirely  of  serum  and  mucus.  The  con- 
stant loss  of  the  fluids  of  the  body  because  of  the  almost 
continuous  vomiting  and  watery  stools  causes  rapid  emaci- 
ation or  " drying  up"  of  the  body.  The  eyes  are  sunken, 
the  f ontanel  depressed,  and  the  infant  goes  quickly  into  col- 
lapse, sometimes  dying  within  twelve  to  thirty-six  hours 
after  the  onset  of  the  disease. 

The  principles  of  the  treatment  of  cholera  infantum  are 
the  same  as  those  of  dysentery,  differing  only  in  the  details. 
Instead  of  a  cathartic,  which,  if  given,  would  be  vomited, 
the  stomach  and  bowels  are  washed  out  immediately  (see 
"Gavage  or  Bowel  Irrigation"). 

The  second  part  of  the  treatment,  the  giving  of  water, 
must  also  be  accomplished  in  a  different  manner.  Water  is 
even  more  urgently  needed  in  this  serious  condition  than  it 


TREATMENT  OF  DIAEEHCEA  155 

is  in  the  other  forms  of  diarrhoea,  but  on  account  of  the 
vomiting  it  will  not  be  retained  when  given  by  mouth.  Water 
in  the  form  of  a  normal  saline  solution  is  given  intravenously 
if  possible,  and,  where  this  is  not  practicable,  subcutaneously 
in  the  scapular  region  or  under  the  breasts,  or  wherever  the 
skin  is  loose.  As  much  as  one  pint,  at  least,  in  twenty-four 
hours  should  be  given,  using  a  large  antitoxin  syringe. 

As  it  usually  cannot  be  retained  by  mouth,  all  medication 
must  be  given  hypodermically.  Grain  y^-g-  to  y^j-  of  strychnia 
may  be  given  every  four  hours.  If  collapse  is  imminent 
or  present,  ten  to  twenty  drops  of  brandy  may  be  given 
every  two  hours.  If  the  brandy  cannot  be  retained  by  mouth, 
it  should  be  given  hypodermically,  especially  in  a  case  of 
emergency. 

The  fever  should  be  reduced  by  friction  baths.  Often 
the  skin  is  moist  and  cold  in  spite  of  a  rectal  temperature 
of  105°  F.  or  over,  and  when  this  is  so,  vigorous  friction 
must  be  used.  A  friction  bath  is  given  in  the  following  man- 
ner :  All  the  clothes  are  removed,  and  the  infant  is  wrapped 
in  a  sheet.  One  part  at  a  time  is  exposed  and  rubbed  vigor- 
ously but  gently  until  the  blood  is  brought  to  the  surface. 
Taking  first  an  arm,  the  extremity  is  moistened  with  equal 
parts  of  alcohol  and  tepid  water,  and  light  friction  continued 
until  the  water  and  alcohol  are  evaporated.  This  is  repeated 
for  five  minutes,  when  the  same  treatment  is  given  to  the 
other  arm,  chest,  abdomen,  back,  and  legs.  The  evaporation 
of  the  water  and  alcohol  cools  the  blood  that  is  brought  to  the 
surface  by  the  friction.  A  warm,  full  bath  to  dilate  the  capil- 
laries in  the  skin  may  be  given  if  the  infant  does  not  react  to 
the  friction  bath.  This  bath  should  be  given  at  a  tempera- 
ture of  105°  F.,  and  should  last  five  minutes. 

Morphine  and  atropin,  used  hypodermically  in  very  small 
doses,  will  often  stop  the  vomiting  and  diarrhoea  quicker  than 
anything  else.  It  should  not  be  used  at  the  onset,  nor  until 


156  SIMPLIFIED  INFANT  FEEDING 

the  bowels  have  been  evacuated  thoroughly  many  times,  nor 
while  there  is  undigested  food  or  fecal  matter  in  the  stools. 
Morphine  is  contra-indicated  when  there  is  stupor  or  much 
drowsiness  and  when  there  is  no  purging.  The  dose  of  mor- 
phine for  a  child  one  year  of  age  is  gr.  ,V,  given  hypoder- 
mically.  It  should  be  combined  with  gr.  -g-^  of  atropin. 
This  may  be  repeated  in  one  or  two  hours  if  the  vomiting 
and  diarrhoea  are  not  improved. 

CASE  XXXIII 

(Illustrating  the  use  of  the  third  metkbod  in  cholera  infantum) 
July  21,  8  P.M.:     Age,  4  months.     Weight,  12  Ib.  6  oz. 

General  Condition. — Well  nourished,  although  the  skin  is  a  little  wrinkled,  due 
to  recent  rapid  loss  of  fluids;  eyes  sunken,  staring  expression,  fontanel  de- 
pressed, body  cold  and  moist;  looks  very  sick. 

Stools. — For  twelve  hours  stools  have  been  so  numerous  they  could  not  be 
counted;  rice-watery  in  character,  composed  almost  entirely  of  serum  and 
mucus. 

Vomiting. — Almost  continuous. 

Appetite. — None. 

Sleep. — Stupor. 

Temperature,  105°  F. 

Chief  Complaint. — Diarrhoea  and  vomiting. 

Previous  Food. — Breast-fed  until  one  month  ago,  when  artificial  feeding  was 
begun.  This  consisted  of  gradually-increased  milk,  water,  and  sugar  mix- 
tures, which  agreed  very  well  with  the  infant  until  a  week  ago,  when  a  mild 
diarrhoea  began.  This  lasted,  untreated,  until  twelve  hours  before  the 
patient  was  seen,  when  cholera  infantum  suddenly  developed. 

Treatment. — Washing  out  the  stomach  with  plain  water  and  irrigating  the 
bowel  with  plain  water.  The  stomach  was  to  be  washed  once.  The  bowel 
was  to  be  irrigated  with  two  quarts  of  warm  water.  Grain  1/200  of  strychnia 
given  subcutaneously  every  four  hours.  Twenty  drops  of  brandy  ir  water 
to  be  given  every  two  hours  if  it  is  retained.  A  tub  bath  at  a  temperature 
of  105°  F.,  followed  by  an  alcohol  friction  bath  every  three  hours  if  the 
patient's  temperature  is  over  103°  F.  No  food  and  no  water  allowed 
until  the  vomiting  stops. 

July  22,  9  A.M.   (12  hours  later)  : 

General  Condition. — Same  as  at  last  visit,  except  that  stupor  has  disappeared. 
Stools. — Not  as  numerous,  but  of  the  same  character. 
Vomiting. — Same  as  at  last  date. 
Appetite. — None. 


TREATMENT  OF  DIARRHCEA  157 

Sleep. — Restless. 

Temperature,  106°  F. 

Treatment. — Grain  y^  of  morphine,  to  be  repeated  in  one  hour  if  vomiting  has 

not   improved.      Brandy,    15    drops   hypodermically,    repeated   if    necessary. 

Eight  ounces  of  sterile,  normal  saline  solution  given  intravenously  in  the 

jugular  vein ;  four  ounces  every  four  hours  to  be  given  subcutaneously,  in  a 

different  place  each  time. 

July  22,  6  P.M.  ( 9  hours  later )  : 

General  Condition. — No  stupor;   infant  looks  brighter. 

Stools. — Three  or  four  since  last  visit,  composed  of  mucus  and  serum. 

Vomiting. — Stopped  one  hour  after  morphine  was  given. 

Appetite. — Nothing  offered. 

Sleep.— A  little. 

Treatment. — One-half  ounce  of  water  by  mouth  every  half  hour,  to  be  gradually 
increased  in  quantity,  one-half  ounce  at  a  time.  Later,  if  well  retained,  to  be 
given  ad  libitum.  Strychnia  continued;  brandy,  15  drops  every  two  hours  by 
mouth. 

July  23  (15  hours  later)  : 

General  Condition. — Much  improved. 

Stools. — Five  since  last  visit;  about  the  same  character. 

Vomiting. — None. 

Appetite. — Taking  a  large  amount  of  water  well. 

Sleep. — Some. 

Temperature,  102°  F. 

Treatment. — Food  prescribed: 

Barley  gruel  ....    1  tablespoonful  ( 14 

oz.)  to  a  quart  of      Feed  2   oz"    (g™dually  increasing  to 
water.  4  oz)  every  2  hours- 

Brandy  discontinued;  strychnia,  gr.  '-/MO  every  6  hours. 

July  24   (1  day  later)  : 
General  Condition. — As  at  last  date. 
Stools. — Four  brown,  watery,  with  mucus. 
Vomiting. — None. 

Appetite. — Hungry;  takes  4  ounces  every  2  hours. 
Sleep. — Fair. 
Temperature,  100°  F. 

Treatment. — Food  prescribed: 

Barley  gruel ....    1  tablespoonful  to  a      Feed  4  oz.  every  2  hours.     Strychnia 

quart  of  water.  continued. 

After  three  days  of  an  exclusive  barley  gruel  diet,  one-third  milk  and  two- 
thirds  water,  boiled  without  sugar,  was  given  (four  ounces  every  two  hours), 
and  the  baby  went  on  to  an  uninterrupted  recovery. 


158  SIMPLIFIED  INFANT  FEEDING 

(4)  Sugar  intoxication  has  a  symptomatology  much  like 
dysentery,  except  that  the  stools  are  not  bloody  and  there 
may  be  no  vomiting.  The  younger,  smaller,  poorly-nour- 
ished infants  who  have  had  digestive  disturbances  previously 
and  who  have  a  lowered  tolerance  for  sugar  are  most  liable 
to  sugar  intoxication.  Since  severe  infectious  diarrhoeas 
show  the  symptoms  that  we  have  formerly  called  intoxi- 
cation, we  must  limit  the  word  to  Finkelstein's  sugar  in- 
toxication, or  use  the  term  in  two  senses :  sugar  intoxication, 
or  intoxication  from  toxins  of  bacterial  origin.  Perhaps 
the  former  would  be  preferable,  since  the  word  toxaemia 
may  be  used  to  express  the  results  of  bacterial  infection. 

The  symptoms  are  sudden  onset,  high  temperature  of 
104°  to  105°  F.,  vomiting,  diarrhoea,  many  watery,  color- 
leas,  or  light  green  stools,  with  a  large  amount  of  mucus. 
In  some  instances  there  is  no  diarrhoea  at  first,  the  intoxi- 
cation being  so  great  that  the  intestines  are  paralyzed,  caus- 
ing the  toxic  matter  to  be  retained  within  the  intestinal  canal. 
The  facial  expression  is  very  characteristic;  the  eyes  are 
sunken  and  seem  to  stare  into  space,  the  mouth  is  open  and 
often  twitching  at  the  corners.  In  other  words,  the  infant 
" looks  sick,"  appearing  almost  as  if  it  were  dying.  There 
is  a  rapid  loss  of  weight.  The  respirations  are  deep  and  may 
be  either  rapid  or  slow  and  sighing.  The  blood  shows  a 
leucocytosis  of  fifteen  or  twenty  thousand.  The  urine 
contains  sugar. 

Unless  there  has  been  a  paralysis  of  the  bowels  and  conse- 
quently no  diarrhoea,  it  is  best  not  to  give  a  cathartic  at  the 
beginning  of  the  treatment.  Pure  water,  unsweetened  or 
sweetened  with  saccharine,  if  it  will  not  otherwise  be  taken, 
should  be  given  in  as  large  amounts  as  the  infant  will  take. 
This  should  be  continued  for  twenty-four  to  forty-eight 
hours,  and  then  an  appropriate  diet,  varying  with  the  con- 
dition of  the  patient,  should  be  given. 

Sugar  intoxication  is  one  of  the  most  satisfactory  classes 


TREATMENT  OF  DIAERHCEA  159 

of  cases  to  treat.  A  wonderful  improvement  usually  takes 
place  in  from  twelve  to  twenty-four  hours.  The  stupor  dis- 
appears, the  temperature  subsides,  and  the  whole  picture  is 
changed. 

(5)  Mechanical  diarrhoea  is  amenable  to  this  same  treat- 
ment. The  term  mechanical  diarrho3a  is  limited  to  that  form 
of  diarrhoea  which  has  been  caused  by  the  ingestion  of  some 
indigestible  article  of  food.  If  the  infant  has  partaken  of 
some  irrational  food,  such  as  grapes,  bananas,  nuts,  etc.,  a 
cathartic,  of  course,  is  necessary.  This  should  be  followed 
by  twenty-four  hours  of  plain  water  diet  to  give  the  gastro- 
intestinal tract  the  needed  rest.  Gruels  may  or  may  not  be 
necessary  after  this  period  of  starvation. 

CABE  XXXIV 
(Illustrating  the  use  of  the  third  method  in  mechanical  diarrhoea) 

December  19:     Age,  12  months.     Weight,  21  Ib. 
General  Condition. — Well  nourished  and  developed;  looks  sick. 
Stools. — For  24  hours,  three  or  four  loose,  watery,  yellow  stools;  no  mucus  or 

blood. 

Vomiting. — None. 
Appetite. — Will  not  eat. 
Sleep. — Poor,  restless. 
Temperature,  104°  F. 
Chief  Complaint. — Diarrhoea,  fever  pain. 
Previous  Food. — This  infant  had  been  fed  upon  the  breast  until  eight  months 

of  age;  since  then  has  had,  in  addition,  cereals  and  milk  from  the  cup  and 

spoon.     Yesterday  had  some  grapes. 
Treatment. — One  tablespoonful  of  castor  oil.     No  food  for  24  hours.     Water 

ad  lil/itum. 

December  20   (1  day  later)  : 
General  Condition. — Seems  well  and  happy. 
Stools. — Three  loose,  green  stools  with  mucus,  no  blood,  following  the  castor 

oil.    None  since.    One  or  two  whole  grapes  were  found  in  the  stools. 
Vomiting. — None. 
A  ppetite. — Hungry. 
Sleep. — Good. 
Temperature,  98.6°  F. 

The  infant  continued  to  do  well.  The  diarrhoea  ceased,  and  on  the  follow- 
ing day  the  usual  diet  was  resumed. 


CHAPTEK  XIII 

ACIDOSIS  ACCOMPANYING  INTESTINAL 
INTOXICATION 

IT  not  infrequently  happens  that  in  the  course  of  a  gas- 
tro-intestinal  disturbance  in  infancy  toxic  symptoms  de- 
velop, which  appear  to  be  the  direct  cause  of  death.  Most 
commonly  the  onset  of  the  toxaemia  is  gradual,  though  in 
some  instances  it  is  sudden.  Nearly  always  there  is  a  pre- 
liminary period  of  diarrhoea,  which  may  be  of  almost  any 
grade  of  severity,  though  it  does  occasionally  happen  that 
the  infant  is  constipated  at  the  time  of  the  onset  of  the 
symptoms.  It  is  not  to  be  taken  for  granted  that  a  toxaemia 
occurring  as  a  part  of  the  picture  of  a  gastro-enteritis  neces- 
sarily means  that  the  infant  is  suffering  from  an  acidosis. 
It  is  a  common  misconception  to  regard  acidosis  as  a  cause 
or  as  of  itself  a  disease  entity,  when  in  reality  it  is  nothing 
more  than  a  symptom  complex,  and  a  diagnosis  which  con- 
tents itself  with  a  mere  label  of  acidosis  is  about  as  con- 
clusive in  the  long  run  as  the  claim  that  the  patient  i? 
Suffering  from  a  fever.  Many  acute  and  chronic  diseases 
present  at  some  time  during  their  course  a  moderate  degree 
Of  acidosis  and  the  mechanism  in  all  instances  is  similar, 
though  the  essential  cause  is  nearly  as  variable  as  the  dis- 
eases themselves.  As  a  matter  of  fact,  acidosis  is  a  super- 
imposed condition,  which  may  of  itself  threaten  life,  but 
which  in  no  way  serves  as  an  explanation  of  disease.  In  the 
toxaemias  of  gastro-intestinal  origin  occurring  in  infants  the 
true  etiological  factors  are  toxic  agents,  which  are  probably 
of  bacterial  origin. 

An  acidosis  is  perhaps  best  defined  as  a  reduction  of  the 
sodium  bicarbonate  of  the  blood  below  the  normal  level. 

160 


ACIDOSIS  AND  INTESTINAL  INTOXICATION    161 

The  clinical  and  laboratory  evidences  of  the  presence  of 
an  acidosis  may  be  briefly  summarized  as  follows : 

(1)  Hyperpncea. 

(2)  Increased  tolerance  for  sodium  bicarbonate. 

(3)  Acetone  odor  of  the  breath  and  acetone  and  diacetic 
acid  found  in  the  urine. 

(4)  Stupor  or  coma, 

(5)  Diminished  urinary  excretion. 

(6)  Improvement  under  alkali  treatment. 

(7)  Special  examinations : 

(a)  Alveolar  air. 

(b)  Blood  plasma. 

(c)  Ammonia  coefficient  of  the  urine. 

(1)  Clinically,  acidosis  is  evidenced  by  more  rapid  and 
deeper    breathing    (increased    pulmonary    ventilation    or 
liyperpncea) ,  and  if  this  sign  is  unaccompanied  by  cyanosis 
it  is  almost  diagnostic. 

(2)  The  determination  of  the  tolerance  for  sodium  bi- 
carbonate is  so  easily  made  as  to  be  fairly  considered  a 
clinical  evidence  of  acidosis.     According  to   Schloss  and 
Stetson,  a  single  maximum  dose  by  mouth  of  sodium  bicar- 
"bonate  of  forty-five  grains  is  sufficient  to  render  the  urine 
of  normal  infants  and  small  children  alkaline.    In  acidosis, 
five  times  this  amount  may  be  required  to  change  the  reac- 
tion of  the  urine. 

(3)  In  a  certain  number  of  cases  of  acidosis  there  is  a 
characteristic  odor  of  acetone  on  the  breath  and  varying 
amounts  of  acetone  and  diacetic  acid  are  present  in  the 
urine.    These  substances  are  not  present  in  amounts  pro- 
portional to  the  severity  of  the  symptoms  nor  to  the  degree 
that  the  carbon  dioxide  tension  of  the  blood  is  reduced.    It 
should  be  added  that  in  a  certain  number  of  severe  cases  of 
acidosis  these  bodies  may  be  entirely  absent  and  that  the 
presence  of  small  amounts  of  these  bodies  must  be  consid- 
ered as  having  no  significance. 

11 


162  SIMPLIFIED  INFANT  FEEDING 

(4)  Stupor  or  even  coma  often  accompanies  an  acidosis, 
though  in  our  opinion  it  is  a  toxic  manifestation  rather  than 
a  consequence  of  acidosis.     In  any  event,  quite  a  severe 
grade  of  acidosis  is  not  infrequently  met  with  in  which  there 
is  little  or  no  stupor. 

(5)  The  excretion  of  the  urine  in  the  acute  stages  of 
acidosis  is  greatly  diminished  and  often  at  this  time  contains 
albumin  and  casts. 

(6)  In  true  cases  of  acidosis  there  is  an  improvement 
of  the  symptoms,  especially  of  the  hyperpnoea,  after  the  cor- 
rection of  the  acidosis  by  alkali. 

(7)  In  a  certain  number  of  cases  the  diagnosis  of  acidosis 
will  necessarily  be  dependent  upon  special  determinations, 
such  as :  (a)  the  decrease  in  the  carbon  dioxide  of  the  blood 
and  the  alveolar  air;  (h)  the  decreased  carbon  dioxide  com- 
bining power  of  the  blood  plasma;  and  (c)  a  high  ammonia 
coefficient  of  the  urine.    A  positive  finding  in  any  one  of  this 
group  of  special  determinations  along  with  a  diarrhoea  in 
which  symptoms  of  intoxication  and  hyperpncea  have  de- 
veloped will  make  the  presence  of  acidosis  a  certainty.1 

There  is  nothing  in  the  animal  economy  that  remains 
more  constant  than  the  reaction  of  the  blood.  Considerable 
additions  of  alkali  or  acids  may  be  made  to  the  blood  without 
much  change  in  the  reaction.  This  is  due  to  the  property 
that  weak  acids  like  carbonic  and  phosphoric  acids  have  of 
not  changing  their  reaction  in  the  presence  of  a  solution 
which  contains  an  excess  of  their  salts. 

The  acids  and  alkalies  in  the  blood  are  in  part  derived 
from  the  food  and  in  part  from  their  constant  production  in 
the  processes  of  metabolism.  The  removal  of  the  acids  from 
the  body  is  effected  in  three  ways :  (1)  gaseous  carbonic  acid 
is  eliminated  through  the  lungs;  (2)  the  fixed  acids  are  ex- 

1  For  methods  of  making  these  special  determinations  see  text-book  "  Phys- 
iology and  Biochemistry  in  Modern  Medicine,"  by  Macleod. 


ACIDOSIS  AND  INTESTINAL  INTOXICATION   163 

creted  through  the  kidneys;  and  (3)  phosphoric  acid  is  to  a 
certain  extent  excreted  through  the  intestines.  A  consid- 
erable damage  to  any  of  these  organs  establishes  a  tendency 
to  a  faulty  elimination  or,  in  other  words,  a  retention  of 
acids.  A  large  depletion  of  the  body  fluids  may  have  the 
same  effect  in  that  there  is  a  deficient  secretion  of  urine 
(Schloss).  As  acids  are  added  to  the  blood  they  will  at 
first  be  neutralized  by  the  "buffer"  substances  of  the  plasma 
— namely,  sodium  bicarbonate  and  the  proteins,  later  by 
"buffer"  substances  in  the  corpuscles  and  perhaps  by  other 
cells  in  the  body.  As  the  acid  concentration  of  the  blood 
(H  ion  concentration)  increases,  there  will  be,  in  addition  to 
their  neutralization  by  the  "buffer"  substances,  an  increase 
in  the  efforts  to  eliminate  them  through  the  normal  channels 
of  excretion.  For  instance,  the  amount  of  carbonic  acid 
present  in  the  blood  progressively  diminishes  as  other  acids 
increase  in  amounts,  this  result  being  accomplished  by  an 
increase  in  the  depth  and  rapidity  of  respiration  rate,  i.e., 
there  is  an  increase  in  the  pulmonary  ventilation.  It  thus 
comes  about  that  a  reaction  of  the  carbon  dioxide  content 
of  the  blood  signifies  a  diminution  of  the  fixed  alkali  of  the 
blood  and  is  therefore  an  important  evidence  of  the  actual 
establishment  of  a  condition  of  acidosis. 

Acidosis  plays  a  role  in  the  symptomatology  of  many 
diseases  of  childhood,  among  which  may  be  mentioned : 

1.  Cyclic  vomiting.  4.  Diabetes. 

2.  Starvation.  5.  Uraemia. 

3.  Post-anaesthesia.  6.  Intestinal  toxaemia. 

There  is  no  pretense  that  this  is  a  complete  list  of  the 
considerations  which  may  be  accompanied  by  acidosis,  but 
it  does  serve  to  indicate  that  acidosis  is  not  of  itself  an 
essential  causal  agent  of  disease.  The  mechanism  of  an 


164  SIMPLIFIED  INFANT  FEEDING 

acidosis  is  always  similar,  though  the  means  by  which  the 
condition  is  brought  about  may  show  great  variation.  In 
a  diabetes,  for  instance,  acidosis  may  result  from  a  per- 
version of  the  normal  metabolic  processes,  while  in  uraemia 
the  underlying  cause  is  found  in  the  inability  of  the 
kidney  to  excrete  waste  products  in  a  normal  fashion.  In 
the  intestinal  toxaemia  the  etiological  causes  are  toxic  agents 
either  of  proteid  or  bacterial  origin.  There  is  a  consider- 
able group  of  anaerobes  that  are  commonly  found  in  the 
gastro-intestinal  tract  that  are  capable  of  elaborating  pow- 
erful toxins  that  have  not  only  a  haemolytic  (commonly) 
action,  but  that  are  also  capable  of  producing  a  widespread 
cloudy  or  fatty  degeneration  of  parenchymatous  epithelium. 
If  these  toxins  are  absorbed  into  the  general  circulation  in 
sufficient  quantities  they  may  cause  death  within  a  few  hours 
with  many  or  all  the  symptoms  commonly  ascribed  to  aci- 
dosis. Certainly  the  cause  of  intestinal  toxaemia  will  in 
many  instances,  if  not  all,  be  found  to  be  one  or  more  of  these 
bacterial  toxins.  It  is  to  be  emphasized  that  the  more  impor- 
tant members  of  this  group  of  anaerobes  are  not  putrefactive 
in  their  main  action,  though  it  has  to  be  confessed  that  they 
best  form  toxins  in  the  presence  of  an  alkaline  reaction  and 
in  a  media  that  is  rich  in  decomposing  protein.  Typical 
members  of  this  group  of  organisms  are  certain  strains  of : 
B.  welchii  (B.  perfrigens,  b.  aerogenes  capsulatus) 

Lethal  dose  of  toxin  for  400  gramme  guinea  pig  as 

high  as  0.05  c.c. 
Vibrion  septique  (b.  malignant  O2dema) 

Lethal  dose  of  toxin  for  400  gramme  guinea  pig  as 

high  as  0.01  c.c. 
B.  oedematiens  (b.  Novyi) 

Lethal  dose  of  toxin  for  400  gramme  pig  as  high 

as  0.01  c.c. 

These  organisms  do  not  cause  putrefaction.     They  break 
down  sugars  rapidly  with  the  formation  of  butyric  acid. 


ACIDOSIS  AND  INTESTINAL  INTOXICATION   165 

B.  sporogenes  (Metchnikoff) 

The  lethal  dose  of  toxin  is  from  2  to  3  c.c. 
The   b.    sporogenes    is    a   putrefactive    organism. 
There  are  a  number  of  other  pathogenic  organisms 
that  are  putrefactive  in  their  action,  but  probably 
they  do  not  on  the  whole  ever  produce  a  toxin  having 
a  greater  strength  than  that  of  the  b.  sporogenes. 
These  organisms  are  all  commonly  found  in  the  upper 
layers  of  the  garden  soil,  in  dust  and  putrid  material.    The 
majority  of  them  are  spore-forming  organisms  (b.  welchii 
is  an  exception),  and  all  of  them  are  resistant  to  ordinary 
amounts  of  heating.    They  grow  well  in  milk,  and  some  of 
them  at  least  are  commonly  found  in  the  gastro-intestinal 
tract,  their  occurrence  there  being  in  the  nature  of  an  acci- 
dental infection  through  the  milk. 

These  toxins  of  bacterial  origin  are  offered  as  the  essen- 
tial causal  agents  of  the  toxaemias  of  infancy  of  gastro-intes- 
tinal origin  which  are  accompanied  by  symptoms  of  acidosis. 
Treatment. — The  treatment  of  acidosis  has,  in  a  general 
way,  two  main  purposes  to  accomplish.  First,  it  is  neces- 
sary to  remove  the  source  from  which  the  toxic  agents  are 
derived  in  order  to  prevent,  as  far  as  possible,  the  continued 
elaboration  of  toxic  agents.  The  second  aim  is  to  return 
the  blood  to  its  normal  reaction  by  an  increase  in  elimination 
and  by  direct  neutralization. 

As  the  toxin  in  this  instance  is  elaborated  in  the  gastro- 
intestinal tract,  it  is  necessary  to  clean  out  the  entire  tract 
in  the  shortest  possible  length  of  time.  This  is  accomplished 
by  a  thorough  and  painstaking  washing  of  the  stomach  and 
large  intestines.  A  single  change  of  water  is  not  sufficient. 
The  stomach  is  to  be  siphoned  out  until  the  returned  water  is 
absolutely  clear,  which  in  many  instances  will  require  five 
or  six  changes  of  water.  As  a  rule,  plain  water  is  not  used, 
but  a  5  per  cent,  solution  of  sodium  bicarbonate.  The  stom- 
ach is  finally  emptied  and  half  an  ounce  of  castor  oil  is  run 


166  SIMPLIFIED  INFANT  FEEDING 

through  the  tube  and  left  in  the  stomach.  The  large  intes- 
tine is  washed  in  the  same  careful  manner.  Every  effort 
is  made  to  reach  the  caecum  by  elevating  the  hips  and  turning 
the  child  from  the  left  to  the  right  side.  The  water  is  run 
into  the  intestine  slowly  and  should  enter  the  rectum  at  a 
temperature  of  102°  F.  When  the  large  intestine  is  filled, 
it  should  be  drained  off  and  the  operation  is  repeated.  Not 
less  than  a  quart  of  water  is  used  for  each  washing,  and  it 
should  be  repeated  until  the  return  is  approximately  clear. 
Here  again  a  5  per  cent,  sodium  bicarbonate  solution  is  pre- 
ferred to  plain  water.  Eight  or  ten  ounces  of  the  sodium 
bicarbonate  solution  is  left  in  the  large  intestine.  It  will 
often  be  necessary  to  repeat  the  washing  of  the  stomach  and 
the  intestines  at  the  end  of  six  or  eight  hours.  If  the  castor 
oil  is  vomited,  it  will  probably  be  necessary  to  wash  the 
stomach  and  large  intestines  at  shorter  intervals,  and  the 
castor  oil,  under  these  circumstances,  should  be  repeated  at 
least  once.  Calomel  is  too  slow  in  its  action  to  be  an  ideal 
cathartic  for  these  cases,  while  magnesium  sulphate  tends 
to  further  deplete  an  already  depleted  body  of  its  fluids. 

An  increase  in  the  elimination  is  also  promoted  by  re- 
placing the  lost  fluids  of  the  body  tissues.  This  may  be 
accomplished  by  direct  injection  of  physiological  salt  solu- 
tion into  a  vein,  by  subcutaneous  injections  or  by  intraperi- 
toneal  injections  of  salt  solution.  The  subcutaneous 
injection  of  physiological  salt  solution  is  a  familiar  method. 
The  chief  objection  to  its  use  in  these  cases  is  the  slowness 
of  the  absorption,  so  that  the  amount  which  will  enter  the 
circulation  in  a  given  length  of  time  is  limited.  Intraperi- 
toneal  injections  of  saline  are  not  dangerous,  may  be  re- 
peated as  often  as  necessary,  are  easily  done,  and  allow  of 
the  absorption  of  large  amounts  of  fluid  in  a  minimum  time. 
The  patient  lies  on  its  back  with  arms  and  legs  restrained 
in  a  sheet  or  jacket.  The  needle  is  inserted  through  the 
linea  alba  just  below  the  umbilicus,  its  point  being  directed 


ACIDOSIS  AND  INTESTINAL  INTOXICATION  167 

upward  and  the  needle  at  an  oblique  angle.  The  skin  and 
subcutaneous  tissues  are  picked  up  between  the  thumb  and 
index  finger  and  pulled  outward  while  the  needle  is  being 
inserted.  The  fluid  is  allowed  to  run  into  the  peritoneal 
cavity  by  gravity  until  the  abdomen  becomes  slightly  dis- 
tended. The  fluid  should  not  be  introduced  too  rapidly  in 
order  to  avoid  the  possibility  of  embarrassing  the  respira- 
tion and  circulation.  One  hundred  and  three  cubic  centi- 
metres, depending  on  the  size  of  the  child,  can  be  introduced 
in  from  fifteen  to  twenty  minutes.  The  temperature  of  the 
solution  when  it  enters  the  peritoneal  cavity  should  be 
about  100°  F.  The  solution  is  a  physiological  salt  solution 
(0.8  per  cent,  sodium  chloride).  A  solution  containing 
sodium  bicarbonate  would  probably  be  dangerous,  owing  to 
its  chances  of  containing  at  least  a  small  amount  of 
sodium  carbonate. 

Direct  neutralization  of  the  acids  in  the  blood  is  accom- 
plished in  a  number  of  ways.  (1)  The  sodium  bicarbonate 
may  be  given  by  mouth.  A  5  per  cent,  solution  is  used  (25 
grains  to  the  ounce  of  water)  and  a  teaspoonful  of  this  solu- 
tion is  given  every  fifteen  minutes.  If  this  is  not  vomited, 
the  quantity  may  be  increased  gradually  up  to  four  tea- 
spoonfuls  every  fifteen  minutes.  (2)  The  sodium  bicar- 
bonate may  be  given  by  rectal  instillation  (Murphy  drip). 
This  is  not  a  very  satisfactory  method  as  it  is  uncertain 
and  the  absorption  is  slow.  (3)  The  sodium  bicarbonate 
may  be  given  under  the  skin.  It  is  necessaiy  to  observe  cer- 
tain precautions  in  the  preparation  of  the  solution.  Sodium 
bicarbonate  that  is  heated  in  the  presence  of  moisture 
changes  to  sodium  carbonate,  a  compound  that  is  irritating 
and  certain  to  cause  a  slough.  It  is  necessary  to  sterilize  the 
sodium  bicarbonate  dry,  and  it  should  not  be  added  to  the 
solution  until  just  before  the  injection  is  made.  Absorption 
of  the  alkali  takes  place  rather  slowly  and  the  quantity  is  to 
a  certain  extent  limited.  From  75  to  100  c.c.  of  a  5  per  cent. 


168 

solution  of  sodium  bicarbonate  may  be  introduced  under  the 
skin  at  one  time.  (4)  The  method  of  choice  of  administering 
alkali  in  urgent  cases  of  acidosis  is  by  intravenous  injection. 
There  are  a  number  of  reasons  why  this  method  is  to  be  pre- 
ferred. When  the  solution  is  run  directly  into  the  blood 
stream  there  is  no  risk  due  to  the  presence  of  sodium  bicar- 
bonate, and  the  incorporation  of  the  alkali  into  the  body 
fluids  takes  place  at  once.  Enough  alkali  can  be  given  at 
once  to  bring  about  an  immediate  improvement  not  only  of 
the  breathing  but  of  the  general  condition.  From  75  to 
100  c.c.  of  a  5  per  cent,  solution  of  sodium  bicarbonate  is 
usually  sufficient  for  the  first  dose.  If  there  is  a  vein  ( scalp, 
jugular,  etc.)  of  sufficient  size  this  method  may  be  used.  The 
superior  longitudinal  sinus  may  be  selected,  though  the 
quantity  of  solution  injected  through  this  channel  should 
not  exceed  75  c.c.,  and  special  precautions  should  be  taken  to 
make  the  injection  slowly.  In  most  instances  it  will  be 
necessary  to  expose  a  vein  by  incision.  The  solution 
should  be  run  into  the  vein  by  gravity  and  should  always 
be  given  slowly. 

The  objective  of  the  alkaline  treatment  of  acidosis  is  to 
render  the  urine  alkaline  in  the  shortest  possible  time. 
Anything*  less  than  this  may  be  considered  at  least  a  par- 
tial failure  in  treatment.  The  method  selected  for  admin- 
istration of  the  alkali  will  be  determined  by  the  exigency  of 
the  case  and  the  skill  of  the  attending  physician.  In  many  of 
the  cases  of  acidosis,  especially  of  the  milder  grade,  enough 
sodium  bicarbonate  may  be  given  by  the  mouth  and  rectum 
to  accomplish  a  satisfactory  result.  The  administration  of 
the  alkali  should  be  continuous  as  long  as  there  is  any  evi- 
dence of  acidosis.  When  an  intravenous  injection  is  neces- 
sary, it  will  be  found  that  the  injection  will  have  to  be 
repeated  one  or  more  times  at  intervals  of  seven  or 
eight  hours. 

Diet  forms  a  very  important  part  of  the  treatment  of 


ACIDOSIS  AND  INTESTINAL  INTOXICATION    169 

aeidosis.  During  the  first  twelve  or  twenty-four  hours  there 
should  be  starvation.  It  is  to  be  remembered  that  the  com- 
plete withdrawal  of  carbohydrates  tends  of  itself  to  bring 
about  a  condition  of  acidosis.  For  this  reason,  the  first  foods 
that  are  allowed  are  the  carbohydrates,  preferably  in  the 
form  of  glucose  or  starches.  Cereal  gruels,  such  as  cream 
of  wheat,  rice  and  barley,  are  to  be  used.  They  must  be 
thoroughly  cooked  (four  hours  in  most  instances).  At  first 
they  are  to  be  given  in  small  quantities  at  three-  of  four- 
hour  intervals  and  the  amount  rapidly  increased.  They 
should  not  be  too  thin,  having  a  consistency  that  wall  barely 
pour.  It  will  often  be  necessary  to  refrain  from  giving  milk 
for  a  number  of  days,  for  the  most  common  mistake  in  the 
treatment  of  cases  of  acidosis  is  a  too  early  return  to  a 
partial  or  full  milk  diet.  When  the  return  to  a  milk  diet  is 
made,  it  should  be  gradual. 


CHAPTER  XIV 
CONSTIPATION  IN  BOTTLE-FED  INFANTS 

BY  constipation  is  meant  a  sluggish  action  of  the  bowels, 
giving  rise  to  stools  that  are  less  frequent  and  harder  and 
drier  than  normal.  Constipation  does  not  necessarily  mean 
a  retention  of  the  faeces. 

The  physician  should  never  take  the  report  of  a  mother 
or  nurse  as  to  the  consistency,  moisture,  and  number  of  the 
stools,  but  should  personally  examine  them.  A  mother  will 
frequently  tell  you  that  her  baby  is  constipated  when  the 
stools  are  merely  harder  or  less  frequent  than  usual.  Strong 
mixtures  of  milk  and  water  produce  stools  that  are  of  a 
firmer  consistency  than  those  occurring  in  infants  taking 
breast  milk  and  some  other  foods.  So  long  as  a  stool  is 
not  actually  dry  or  crumbly  it  cannot  be  called  constipated. 
A  stool,  too,  may  be  normal  in  consistency  when  the  infant 
has  become  habituated  to  cathartics,  enemas,  or  supposi- 
tories, and  therefore  evacuation  of  the  bowels  is  not 
voluntary. 

The  normal  number  of  stools  varies  with  the  infant  and 
with  the  food  given.  One  a  day  is  sufficient  at  any  age, 
but  for  younger  infants  two  are  preferable.  All  mothers, 
and  many  physicians,  look  upon  constipation  as  a  much 
more  serious  condition  than  it  actually  is.  Persistent  consti- 
pation throughout  the  bottle  period  will  not,  in  itself,  cause 
any  nutritional  disturbances.  As  a  matter  of  fact,  an  infant 
may  gain  progressively  in  weight  and  do  well  in  every 
other  respecjt  where  constipation  exists.  Constipation  fol- 
lowing a  diarrhoea  is  always  welcome,  because  it  indicates 
that  the  sugar  and  the  various  other  elements  of  the  food 
may  be  increased  without  doing  any  harm.  This  fact  should 
be  explained  to  the  mother,  lest  she  worry  about  the  consti- 
170 


CONSTIPATION  IN  BOTTLE-FED  INFANTS     171 

pation  and  perhaps  give  a  cathartic  without  being  instructed 
to  do  so,  thus  causing  a  recurrence  of  the  diarrhoea. 

The  causes  of  constipation  in  bottle-fed  infants  are  many 
and  varied.  Most  of  them  have  to  do  originally  with  the 
food,  the  abuse  of  cathartics  usually  serving  to  increase  the 
difficulty.  The  cases  that  are  the  most  resistant  to  treatment 
are  those  that  have  received  cathartics  of  various  sorts  over 
a  long  period  of  time.  With  such  cases  it  is  never  advisable 
to  give  cathartics  until  all  possible  dietetic  measures  have 
failed. 

CAUSES    OF    CONSTIPATION    IN    THE    BOTTLE-FED 

(1)  Gastric  indigestion  (7)  Excessive  vomiting  or 

(2)  Too  much  fat  lack  of  appetite 

(3)  Too  much  sugar  (8)  Boiled  milk 
Too  little  sugar                       (9)  Cathartics 
Too  little   or  too  weak  (10)  Habit 

food  leaving  little  resi-     (11)  Organic    lesions:    Fis- 

due.  sure     anus;     abnor- 

(6)  Too  concentrated  food  mally     small     anus; 

hemorrhoid;  polypus 

(1)  Gastric  Indigestion. — Any  food  which  causes  gastric 
indigestion  may   cause   either   diarrhoea   or   constipation. 
Some  bottle-fed  infants  have  a  tendency  to  diarrhoea,  and 
whenever  there  is  a  dietetic  error  of  any  sort  their  bowels 
become  loose  at  once.    Others  have  a  tendency  to  constipa- 
tion, and  gastric  indigestion  causes  the  bowels  to  become 
sluggish  in  their  action.  Dietetic  errors  have  been  fully  dis- 
cussed under  "Diarrhoea,"   "Vomiting,"   and   "Loss   of 
Appetite. ' ' 

Treatment. — Constipation  due  to  gastric  indigestion 
must  have  treatment  appropriate  for  the  causative  factor. 

(2)  Too  Much  Fat. — The  practice  of  increasing  the  fat 
to   overcome  constipation  is   no   longer  popular.     If  the 
food  is  deficient  in  fat,  increasing  it  slightly  will  have  a 
beneficial  action  upon  the  bowels,  but  if  the  fat  is  already 
sufficient  in  quantity  and  there  is  constipation,  increasing 


17-2  SIMPLIFIED  INFANT  FEEDING 

it  may  only  serve  to  make  the  constipation  worse.  The 
author  saw  far  more  constipation  in  bottle-fed  infants  when 
he  was  using  top  milks  than  he  has  seen  with  whole-milk 
mixtures  properly  used.  Fat  constipation  is  seldom  caused 
by  whole  milk  properly  diluted,  and  for  this  reason  those 
who  do  not  use  creams  or  top  milks  will  not  often  have  this 
difficulty  to  deal  with. 

Pat  constipation  is  brought  about  by  the  fats  splitting 
into  fatty  acids  in  the  intestines.  The  alkalies,  secreted  by 
the  intestinal  mucosa,  unite  with  these  fatty  acids  and  form 
insoluble  soaps.  Such  a  condition  of  affairs  gives  rise  to 
hard,  dry  stools  that  are  white  or  gray  in  color  and  often 
crumbly  in  appearance,  sometimes  resembling  sand.  If  this 
condition  is  allowed  to  continue,  mucus  may  appear  and  the 
stools  become  green  in  color,  or,  finally,  diarrhrea  may  follow. 

Treatment. — An  infant  that  has  fat  indigestion  from 
cream  or  top-milk  mixtures,  therefore,  should  have  this 
excessive  fat  diminished  by  feeding  whole  milk,  water,  and 
sugar  in  the  proper  quantity. 

CASE  XXXV 

(Illustrating  the  use  of  whole  milk,  water,  and  sugar  to  relieve  constipation 
from  excessive  fat) 
May  19:     Age,  5  months  2  weeks:     Present  weight,  11  Ib.  10  oz. 

Birth  weight,  4  Ib.  8  oz. 
General  Condition. — Poorly  nourished,  color  fair,  good  musculature,  no  bony 

deformities.    Needs  from  50  to  55  calories  per  pound  per  day. 
Stools. — Has  been  constipated  for  about  a  month,  having  one  hard  stool  a  dayt 

either  with  the  aid  of  an  enema  or  suppository. 
Vomiting. — None. 

Appetite. — Good;  takes  all  the  food. 
Sleep. — Good  during  the  day,  poor  at  night. 
Temperature,  98.6°  F. 
Chief  Complaint. — Constipation. 

Previous  Food. — Top-milk  mixtures  since  birth.     A  month  ago  increased  in 
strength  to: 

9  oz.  top  milk  (12  per  cent,  fat)  ..  15  oz.  )  Fed  4+  oz.  every 
Water 15  oz.  [ U  3  hours,  7  feed- 
Milk  sugar li/2  oz.  ings  in  24  hours. 


CONSTIPATION  IN  BOTTLE-FED  INFANTS    173 

Treatment. — Food  prescribed: 

Whole  milk 20  oz.  "I  400  cals.       Divide  into  7  feedings.  Feed 

Water 20  oz.  j  6-  oz.  every  3  hours  at  6, 

Dextri-maltose 1  oz.  120  cals.  9,    12   A.M.,   3,   6,   9   P.M., 

and  2  A.M. 

520  cals.,  or  44+  cals.  per  pound. 

May  26   (7  days  later)  :     Weight,  11  Ib.  13  oz. 

Gain,  3  oz. 

General  Condition. — The  same. 

Stools. — One  a  day,  softer  than  formerly,  with  a  small  enema  each  day. 
Vomiting. — None. 
Appetite. — Good. 
•Sleep. — Good. 

Treatment. — Food  prescribed: 

Milk 21       oz.  420  cals.       Divide  into  7  bottles.    Feed  6  oz. 

Water 21       oz.  every  3  hours  as  before. 

Dextri-maltose  ...      1%  oz.  180  cals. 

600  cals.,  or  50-{-  calories  per  pound. 
June  2   (7  days  later)  :       Weight,  12  Ib.  6  oz. 

Gain,  9  oz. 

General  Condition. — Improved. 
Stools. — One  normal  each  day  tnthout  enema. 
Vo  mi  ting. — None. 

Appetite. — Good ;  takes  all  the  food. 
JSleep. — Excellent. 
Treatment. — Food  unchanged. 

(3)  Too  much  sugar  is  the  cause  of  constipation  only 
when  the  sugar  is  increased  far  beyond  the  limit  of  the 
infant's  capacity.  During  our  early  studies  with  sugar, 
when  it  was  considered  a  laxative  under  all  circumstances, 
large  amounts  were  used  in  an  attempt  to  overcome  stubborn 
constipation.  This  was  seldom  helpful.  Occasionally  an 
infant  who  was  getting  one  and  a  half  ounces  of  sugar  in 
the  twenty-four-hour  amount  would  be  benefited  by  increas- 
ing the  sugar  to  two  ounces  in  the  twenty-four-hour  amount, 
but  this  was  not  universally  true.  On  the  other  hand,  many 
•constipated  infants  whose  sugar  was  increased  to  more  than 


174  SIMPLIFIED  INFANT  FEEDING 

two  ounces  in  twenty-four  hours  were  made  more  constipated 
by  the  treatment. 

Treatment. — In  constipated  infants  whose  twenty-four- 
hour  quantity  of  food  contains  two  ounces  of  sugar,  or  even 
one  and  a  half  ounces,  this  condition  may  be  remedied  by 
cutting  down  the  sugar  to  one  ounce  in  the  twenty-four-hour 
amount  when  the  deficiency  in  the  sugar  is  made  up  by 
adding  more  milk  to  the  food. 

The  normal  amount  of  sugar  for  an  infant  under  ten 
pounds  of  weight  is  one  ounce  in  the  twenty-four-hour 
amount.  Infants  weighing  more  than  ten  pounds  may  have 
one  and  one-half  ounces  in  the  twenty-four-hour  amount. 
When  the  food  is  correct  in  every  other  way,  it  is  rarely 
necessary  to  give  more  than  one  and  one-half  ounces  of 
sugar,  and  two  ounces  is  the  maximum  quantity  that  should 
ever  be  used  for  any  bottle-fed  infant. 

As  to  the  kinds  of  sugar  which  are  best  used  to  over- 
come constipation,  malt  soup  extract  seems  to  act  most 
favorably  in  infants  who  are  stubbornly  constipated,  prob- 
ably because  of  the  potassium  carbonate  which  it  contains. 
Malt  sugar  itself  (dextrin  and  maltose)  does  not  seem  to 
have  this  action  unless  potassium  carbonate  is  added  to  it. 
The  author  has  never  been  convinced  that  malt  sugar  was 
more  laxative  than  cane  sugar,  or  milk  sugar,  nor  that  the 
reverse  was  true.  Mead's  Dextrimaltose  No.  3  contains 
potassium  carbonate  instead  of  common  salt  (sodium  chlo- 
ride) which  is  in  the  No.  1.  Constipation  is  often  imme- 
diately overcome  by  changing  from  No.  1  to  No.  3. 

CASE  XXXVI 

(Illustrating  a  case  of  constipation  from  too  much  sugar) 
April   W'.     Age,  4  months.     Present  weight,  12  Ib.  9  oz. 

Birth  weight,  7  Ib. 
General  Condition. — Normal,  fat,  well-nourished  infant.     Xeeds  from  45  to  50 

calories  per  pound  per  day. 

Stools. — One,  constipated,  a  day  with  the  aid  of  a  soap  suppository.  Move- 
ments sometimes  so  hard  that  a  streak  of  blood  could  be  seen  on  the  outside 
of  the  stool. 


CONSTIPATION  IN  BOTTLE-FED  INFANTS  175 

Vomiting. — A  little,  three  or  four  times  a  day. 
Appetite. — Seems  hungry. 
Sleep. — Fair ;  cries  a  good  deal  from  colic. 
Chief  Complaint. — Constipation. 

Previous  Food: 

Milk    18       oz.  )  360  cals.     Fed  5  oz.    every  3  hours,  7  feed- 

Water     ....    18       oz.  j-  unboiled  ings  in  24  hours. 

Cane  sugar..     2*4  oz.  300  cals. 

C60  calories,  or  53-  calories  per  pound. 
Treatment. — Food  prescribed: 

Milk   21  oz.  |  420  cals.      Divide  into  6  feedings.    Feed  6 

Water 21  oz.  [  u  oz.  every  3  hours  at  6,  9,  12 

Cane  sugar 1  oz.  120  cals.          A.M.,  3,  6,  9  P.M. 

540  cals.,  or  43+  calories  per  pound. 

April  17   (1  week  later)  :    Weight,  12  Ib.  12  oz. 
Gain,  3  oz. 

General  Condition. — The  same. 

Stools. — One  voluntary  a  day,  still  somewhat  hard. 

Vomiting. — None. 

Appetite. — Hungry. 

£lcep. — Good. 

Treatment. — Food   prescribed: 

Milk    21       oz.  |  .         420  cals.     Divide  into  7  bottles.    Feed  6  oz. 

Water     ....   21       oz.  \  unb  every  3  hours  as  before. 

Cane  sugar..      IV2  oz.  180  cals. 

600  calories,  or  47+  calories  per  pound. 

This  infant  continued  to  improve  and  the  stools  were  normal  and  volun- 
tary thereafter. 

(4)  Too  Little  Sugar. — It  may  seem  paradoxical  to  say 
that  too  little  sugar  in  the  food  may  cause  constipation  and 
that  too  much  sugar  will  cause  the  same  condition.  That 
too  little  sugar  causes  constipation  has  been  demonstrated 
over  and  over  again  by  increasing  the  sugar  in  an  infant's 
food  that  is  deficient  in  sugar.  Infants  who  have  consti- 
pation following  diarrhoea  and  whose  sugar  has  been  stopped 
on  account  of  the  diarrhoea  will  have  normal  voluntary  move- 
ments when  the  sugar  is  properly  increased.  After  a  diar- 
rhoea the  constipation  brought  about  by  stopping  the  sugar 
is  desirable,  and  it  is  important  that  the  sugar  be  gradually 


176  SIMPLIFIED  INFANT  FEEDING 

increased  for  fear  of  a  recurrence  of  the  diarrhoea.  Under 
these  conditions  there  is  absolutely  no  doubt  that  sugar  acts 
as  a  laxative. 

Treatment. — The  treatment  of  constipation  due  to  too  lit- 
tle sugar  consists  in  gradually  increasing  the  amount  of 
sugar  in  the  food  up  to  one  ounce  for  the  infant  under  ten 
pounds  in  weight  and  one  and  a  half  ounces  for  an  infant 
over  this  weight.  Occasionally  the  older,  larger  infant  may 
receive  two  ounces  in  the  twenty-four-hour  amount  and  the 
constipation  be  benefited  thereby. 

CASE  XXXVII 
(Illustrating  a  case  of  constipation  from  too  little  sugar) 

September  15:      7  months:     Present  weight,  14  Ib.  2  oz. 

Birth  weight,  5  Ib.  6  oz. 

General  Condition. — Small,  but  fat,  well  nourished,  good  color  and  good  muscu- 
lature, no  bony  deformities.  Needs  from  40  to  45  calories  per  pound  per  day. 

Stools. — Since  recovering  from  an  attack  of  diarrhoea  a  month  ago  has  been 
constipated,  having  only  one  hard  movement  a  day,  and  that  with  a  sweet- 
oil  or  water  enema. 

Vomiting. — None. 

Appetite. — Satisfied. 

Sleep. — Good. 

Temperature,  98.6°  F. 

Chief  Complaint. — Constipation. 

Previous  Food: 

Milk 24  oz- \ij_-i_j    48°  cals-       Fed  8  oz.  every  3  hours,  6  feedings 

Water 24  oz.  j  in  24  hours. 

Dextri-maltose. .    %  oz.  90  cals. 


570  calories,  or  40+  calories  per  pound. 

Treatment. — Food  prescribed : 

Milk 24  oz.|  bojled  480  cals.       Divide  into  6  feedings.    Feed  8  oz. 

Water 24  oz.J  every  3  hours,  at  6,  9,  12  A.M., 

Dextri-maltose..      1  oz.  150  cals.  3,  6,  9  P.M. 

(In  3  days  increase 

sugar  to  1%  oz.)  630  calories,  or  45-  calories  per  pound. 


CONSTIPATION  IN  BOTTLE-FED  INFANTS    177 

September  21    (6  days  later)  :     Weight,  14  Ib.  9  oz. 

Gain,  7  oz. 

General  Condition. — The  fame. 
Stools. — One  voluntary,  still  somewhat  hard. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk 24       oz.l ,.,,      480  cals       Divide  into  6  feedings.     Feed  8 

Water 24       oz.  j  oz.  every  3  hours  as  before. 

Dextri-maltose. .      lys  oz.  180  cals. 

660  calories,  or  45+  calories  per  pound. 

Within  the  next  few  days  there  waa  one  normal,  voluntary  stool  a  day, 
soft  and  smooth. 

The  reason  the  milk  was  given  boiled  was  because  this  particular  infant 
had  had  diarrhoea  two  or  three  times  during  its  life  when  raw  milk  was  given, 
and  raw  milk  given  even  for  a  day  would  cause  two  or  three  loose  stools  contain- 
ing hard  curds. 

(5)  Too  Little  or  Too  Weak  Food  Having  Little  Residue. — 
Too  weak  food  acts  in  two  ways  in  causing  constipation: 
First,  it  does  not  leave  enough  residue  in  the  intestinal 
canal  to  form  a  stool  sufficient  in  size  to  be  evacuated 
once  in  twenty-four  hours ;  and,  second,  an  atonic  condition 
of  the  bowels  is  brought  about  by  the  underfeeding.  It  may 
easily  be  seen  that  if  the  muscles  and  other  organs  of  the 
body  atrophy  and  the  infant  is  feeble,  the  same  condition 
may  be  found  in  the  muscles  of  the  intestinal  wall  and  thus 
cause  constipation.  The  lack  of  residue  may  be  due  not 
only  to  underfeeding  with  various  weak  mixtures  of  milk, 
top  milk  or  cream,  but  to  certain  proprietary  foods,  malted 
milk,  and  foods  which  are  made  up  of  starches  or  sugars  and 
used  without  milk.  If  there  is  not  enough  material  in  the 
intestinal  canal  to  form  a  good-sized  movement  each  day, 
the  proper  peristaltic  action  of  the  bowel  will  not  be  excited. 
Infants  underfed  in  this  way  are  ill-nourished  and  emaciated, 
12 


178  SIMPLIFIED  INFANT  FEEDING 

and  many  of  them  have  vomiting  and  loss  of  appetite  as  well 
as  constipation. 

Treatment. — Constipation  is  not  the  most  urgent  symp- 
tom to  be  treated  in  infants  thus  underfed,  but  the  treatment 
for  the  constipation  also  improves  the  infant's  nutrition  and 
digestive  disturbances.  If  too  weak  dilutions  of  milk  and 
water  are  being  used,  the  strength  should  be  increased.  If 
malted  milk  or  any  of  the  proprietary  foods  without  milk 
are  being  used,  they  should  be  stopped  at  once  and  weak 
dilutions  of  milk  begun,  usually  one-third  milk  and  two- 
thirds  water.  If  no  sugar  has  been  given  in  the  previous 
food,  the  sugar  should  be  added,  one  teaspoonful  at  a  time. 
If  the  food  previously  given  has  contained  the  proper  amount 
of  sugar,  it  does  no  harm  to  start  with  the  same  amount 
of  sugar  in  the  new  food,  or  an  increased  amount,  provided 
there  is  no  vomiting  or  lack  of  appetite. 

CASE  XXXVIII 

(Illustrating  a  case  of  constipation  from  too  weak  a  food) 
July  5:     Age,  4  months.     Present  weight,  9  Ib.  8  oz. 

Birth  weight,  7  Ib. 
General  Condition. — Poorly  nourished,  pale,  poor  musculature;  no  evidence  of 

rickets.    Cries  vigorously.    Needs  55  calories  per  pound  per  day. 
Stools. — For  two  weeks,  one  a  day,  a  teaspoonful  of  milk  of  magnesia  being 

given  at  night.     ATo  movement  without  this. 
Vomi  ting. — None. 
Appetite. — Hungry. 
Sleep. — Poor,  both  night  and  day. 
Temperature,  98.6°  F. 
Chief  Complaints. — Constipation,  crying,  not  gaining  in  weight. 

Previous  Food. — This  infant  was  artificially  fed  during  the  first  two  months 
of  its  life.  Then  had  a  wet  nurse  for  one  month,  during  which  time  very 
good  progress  was  made.  For  the  last  month  has  had: 

Milk 15  oz.1  300  cals.       Fed  4+  oz.  every  3  hours,  7  feed- 
Water 15  oz. }  C  ings  in  24  hours. 

Cane  sugar  ...   y2  oz.  60  cals. 

360  calories,  or  38-  calories  per  pound. 


CONSTIPATION  IN  BOTTLE-FED  INFANTS    179 

Treatment, — Stop  milk  of  magnesia;   give  water  enema  if  bowels  have  not 
moved  within  36  hours. 

Food  prescribed: 

Milk   20  oz.  )  .         400  cals.      Divide  into  7  feedings.    Feed  6- 

Water 20  oz.  J  b(nl                                oz.  every  3  hours  at  6,  9,  12 

Cane  sugar 1  oz.  120  cals.          A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

520  calories,  or  55-  calories  per  pound. 
July  8  (3  days  later):     Weight,   9   Ib.    12  oz. 

Gain,  4  oz. 

Genera  I  Condition. — Unchanged. 
Stools. — One  normal,  soft,  smooth  stool  a  day  without  milk  of  magnesia  or 

enema. 

Vomiting. — None. 
Appetit  e. — Hungry. 
Sleep. — Good. 
Treatment. — Food  unchanged. 

July  29    (3  weeks  later )  :     Weight,  10  Ib.  12  oz. 

Gain,  1  Ib. 

(Has  only  gained  3  oz.  in  last  week. ) 
General  Condition. — Much  improved. 

Ktools. — For  the  last  week,  one  hard  stool  a  day.     Seldom  has  to  use  enema. 
Yotn  it  ing. — Xone. 
Appetite. — Hungry. 
Sleep. — Good. 

With  the  increase  in  weight,  the  food  not  being  increased,  the  infant  had 
been  getting  less  than  fifty  calories  per  pound.  This  was  the  cause  of  the 
constipation  and  insufficient  gain  during  the  last  week.  The  food  should  have 
been  increased  a  week  earlier  but  the  patient  lived  at  a  distance  and  was 
unable  to  bring  the  baby  to  the  office  sooner. 


Treatment. — Food  prescribed : 

Milk   20      oz.  }       .     i    400  cals.      Divide  into  7  bottles.     Feed  6- 

Water 20       oz.   j"  oz.  every  3  hours  as  before. 

Cane  sugar   ...      lys  oz.  180  cals. 

580  calories,  or  54-  calories  per  pound. 


This  brought  the  calories  up  to  the  required  number  per  pound.  The 
bowels  remained  normal  with  a  gradual  increase  in  the  food  to  meet  the  caloric 
needs,  as  the  infant's  weight  increased. 

(6)  Too  Concentrated  Food. — Strong  dilutions  occasion- 
ally cause  constipation.  Some  years  ago  when  the  simple 
dilutions  of  whole  milk  were  first  being  used  by  the  author, 
he  found  much  more  constipation  than  at  the  present  time 
because  stronger  mixtures  were  given.  At  that  time  smaller 


180  SIMPLIFIED  INFANT  FEEDING 

quantities  were  given  at  each  feeding,  which  necessitated 
adding  a  smaller  quantity  of  water  to  the  milk  and  sugar 
which  was  required  to  make  up  the  proper  number  of 
calories.  For  instance,  an  infant  weighing  eleven  and  one- 
half  pounds  requiring  fifty  calories  per  pound  must  have 
575  calories  a  day.  Such  an  infant  could  take  one  and  one- 
half  ounces  of  sugar  a  day  or  180  calories.  This  would  leave 
395  calories  of  milk  or  about  twenty  ounces.  Formally  the 
formula  would  be  made  up : 

Milk 20  oz.  400  cals.      Seven    feedings    of    four    ounces 

Water    10  oz.  each. 

Sugar    1%  oz.  180  cals. 

580  cals. 

This  strong  solution  would  often  cause  constipation.  At  present  we  give 
five  and  a  half  to  six  ounces  at  a  feeding,  and  would  make  up  the  formula : 

Milk 20  oz.  400  cals.      Seven  feedings  of  six  ounces  each. 

Water    20  oz. 

Sugar  lys  oz.  180  cals. 

580  cals. 
This  dilution  rarely  causes  constipation. 

(7)  Excessive  Vomiting  or  Lack  of  Appetite. — For  the  same 
reason  that  too  little  food  or  too  weak  food  will  cause  con- 
stipation, the  infant  who  vomits  the  larger  part  of  its  food 
will  be  constipated.    This  is  seen  in  pyloric  stenosis,  where 
the  food  is  vomited  instead  of  passing  through  the  pylorus, 
or  when  for  any  reason  a  great  part  of  the  food  is  vomited. 
Lack  of  appetite  acts  in  the  same  way,  because  insufficient 
food  is  taken. 

Treatment. — The  treatment  of  constipation  due  to  these 
causes  consists  in  treating  the  vomiting  and  lack  of  appetite. 
(See  pages  184,  209.) 

(8)  Boiled  Milk. — Just  as  boiled  milk  will  help  to  control 
diarrho3a,  so  will  it  produce  and  aggravate  constipation 
after  the  other  digestive  disturbances  have  been  overcome 
by  the  boiled  milk. 

Treatment. — Where  boiled  milk  has  been  used  for  vomit- 
ing or  diarrhoea,  and  the  symptoms  have  ceased  and  both  the 


CONSTIPATION  IN  BOTTLE-FED  INFANTS    181 

milk  and  sugar  have  been  increased  up  to  the  quantity  that 
fulfils  the  infant's  caloric  requirements,  the  milk  should 
no  longer  be  boiled  if  there  is  constipation.  This  is  also 
true  of  constipated  infants  not  having  had  digestive  dis- 
turbances, but  who  have  been  given  boiled  milk  for  some 
other  reason.  If  vomiting  is  present,  the  constipation  be- 
comes secondary,  and  it  is  best  to  give  an  enema  of  plain 
water  every  day  rather  than  to  stop  boiling  the  milk. 

(9)  Cathartics. — The  most  stubborn  form  of  constipa- 
tion that  we  have  to  deal  with  occurs  in  infants  who  have 
received  daily  doses  of  castor  oil,  castoria,  rhubarb  and 
soda,  calomel,  or  any  of  the  other  active  cathartics.  If  this 
abuse  of  cathartics  has  extended  o"ver  a  long  period  of  time, 
it  is  almost  impossible  to  overcome  the  constipation  by 
dietetic  measures.  Enemas  and  suppositories,  when  used 
over  a  long  period  of  time,  are  nearly  as  bad.  When  advis- 
ing a  cathartic  or  an  enema  a  mother  should  always  be 
told  that  it  is  only  a  temporary  measure  to  make  the  bowels 
move  until  the  food  can  be  so  changed  as  to  permanently  over- 
come the  constipation. 

Treatment. — If  dietetic  measures  fail,  milk  of  magnesia 
is  the  least  harmful  laxative  to  use.  After  six  months  of 
age,  unsweetened  apple-sauce,  prune  pulp,  or  other  fruit 
juices  may  be  used  instead  of  the  milk  of  magnesia.  Orange 
juice  should  be  given  to  all  bottle-fed  infants  over  two 
months  of  age  whether  they  are  constipated  or  not,  provided 
there  is  no  contra-indication.  It  is  always  well  to  begin 
orange  juice  in  very  small  amounts,  one  teaspoonful  twice 
a  day,  half  way  between  two  feedings,  and  each  week  the 
quantity  is  increased  one  teaspoonful  at  a  time  until  the 
infant  is  getting  the  juice  of  half  an  orange  twice  a  day. 
After  one  year  of  age,  scraped  raw  apple  is  more  laxative 
than  orange  juice.  A  ripe  apple  is  cut  in  half  with  the  skin 
on,  the  core  taken  out,  and  the  apple  is  lightly  scraped  with 
a  spoon,  being  careful  to  get  no  lumps  in  it.  Only  a  tea- 
spoonful  should  be  given  the  first  few  days,  and  this  amount 
gradually  increased  up  to  half  an  apple  twice  a  day  if  neces- 


182  SIMPLIFIED  INFANT  FEEDING 

sary  to  overcome  the  constipation.  A  ripe  pear  may  be 
used  in  the  same  way.  After  eight  months  of  age  there  are 
many  laxative  foods  that  can  be  used,  and  even  though 
these  stubborn  cases  have  milk  of  magnesia  up  to  this 
age,  the  constipation  can  be  permanently  cured  by  die- 
tetic measures. 

CASK  XXXIX 

(Illustrating   constipation  from  the  excessive  use  of  cathartics) 
March  23:     Age,  11  months  3  weeks.     Present  weight,  20  Ib.  4  oz. 

Birth  weight,  unknown. 

General  Condition. — Well  nourished,  well  developed,  good  color,  excellent 
musculature. 

Stools. — Since  eight  months  of  age,  when  weaned  from  the  breast,  infant  has 
been  constipated.  Various  measures  were  tried  to  overcome  it,  and  recently 
milk  of  magnesia,  even  a  teaspoonful  as  often  as  three  or  four  times  a  day, 
failed  to  move  the  bowels  unless  a  soap  and  water  enema  was  given  every  day. 

Vomiting. — None. 

Appetite. — Good. 

Sleep. — Excellent. 

Temperature,  98.6°  F. 

Chief  Complaint. — Constipation. 

Previous  Food. — Breast-fed  entirely  for  the  first  eight  months;  since  then  has 
had  sis  or  seven  ounces  of  undiluted  milk  every  three  hours,  besides  the  breast 
twice  a  day. 

Treatment. — Stop  milk  of  magnesia.     Use  suppository  once  a  day  if  necessary. 

For  diet  given,  see  page  321. 

April  6  (2  weeks  later)  :  The  infant  has  taken  the  food  well,  and  the  bowels 
have  moved  once  a  day,  a  soft,  normal  movement  without  the  use  of  a  sup- 
pository during  the  last  three  or  four  days. 

(10)  Habit. — Habit  has  long  been  recognized  as  a  cause 
of  constipation  in  older  children  and  adults,  but  enough  em- 
phasis has  not  been  placed  upon  habit  in  infancy.    At  three 
or  four  months  of  age  every  infant,  whether  constipated  or 
not,  unless  there  is  malnutrition  or  some  other  such  contra- 
indication, should  be  placed  upon  a  vessel  once  or  twice  a 
day.    It  is  astonishing  to  see  how  readily  such  young  infants 
learn  the  meaning  of  this  procedure.     The  vessel  should 
be  small,  exactly  fitting  the  infant's  buttocks,  and  should  be 
placed  in  the  nurse's  or  mother's  lap,  and  the  infant's  back 
supported  while  the  bowels  are  being  evacuated. 

(11)  Organic  Lesions. — Fissures  are  usually  caused  by 


CONSTIPATION  IN  BOTTLE-FED  INFANTS    183 

previous  constipation,  the  stool  being  so  large  and  hard 
that  in  passing  the  anus  a  fissure  is  made.  In  addition  to 
the  constipation,  then,  the  pain  of  evacuating  the  bowels 
prevents  the  infant  from  having  a  stool  when  the  inclination 
is  aroused.  A  stick  of  silver  nitrate  should  be  applied  to 
the  fissure  once  in  three  or  four  days  until  healed  and  the 
proper  measures  taken  to  overcome  the  cause  of  the  orig- 
inal constipation. 

An  abnormally  small  anus  is  not  infrequently  seen.  This 
condition  should  be  remedied  by  stretching  the  anus  every 
two  or  three  days  with  the  finger,  first  inserting  the  little 
finger  for  only  a  short  distance  and  later  the  index-finger. 
Hemorrhoids  and  polypi  are  rarely  seen  in  very  young 
infants,  but  when  they  occur  appropriate  treatment  should 
be  used. 

TREATMENT  OF  CONSTIPATION  THAT  HAS  RESISTED  DIETETIC 
MEASURES  WHILE  BOTTLE-FED 

Infants  are  occasionally  seen  who  remain  constipated 
in  spite  of  all  that  can  be  done  dietetic-ally.  After  a  faith- 
ful trial  of  dietetic  measures,  infants  under  six  months  of  age 
may  have  milk  of  magnesia,  used  in  as  small  quantities  as 
will  bring  about  one  good-sized  normal  movement  a  day. 
It  is  best  to  begin  by  giving  one  teaspoonful  of  milk  of 
magnesia  in  one  or  two  bottles  a  day.  If  this  does  not  suffice, 
the  same  amount  may  be  given  in  one  or  two  more  of  the 
bottles,  and  so  on  until  enough  is  given  to  bring  about  a 
voluntary  evacuation.  It  is  particularly  useful  in  infants 
too  young  to  take  orange  juice  or  scraped  fruits,  and  should 
be  discontinued,  if  possible,  so  soon  as  the  age  of  six  or  seven 
months  is  reached,  when  fruit  juices  can  be  substituted  in 
fairly  large  quantities.  If  the  milk  of  magnesia  has  to  be 
continued  longer  than  this,  it  does  not  do  so  much  harm  as 
the  more  violent  cathartics,  and  during  the  second  year,  when 
the  child  is  put  upon  solid  food,  the  diet  can  be  so  regulated 
as  to  overcome  the  constipation  permanently. 


CHAPTER  XV 

VOMITING  IN  BOTTLE-FED  INFANTS 

VOMITING  in  bottle-fed  infants  may  be  classified  under 
two  broad  heads : 

Acute  vomiting. 
Habitual  vomiting. 

These  may  be  sub-classified  according  to  their  causes. 

ACUTE  VOMITING 

Acute  vomiting  is  that  form  which  occurs  suddenly  in  an 
infant  who  has  previously  been  free  of  gastric  disturbances 
or  in  an  infant  who  has  had  gastro-intestinal  disturbances 
of  a  more  chronic  nature.  Acute  vomiting  with  a  sudden 
onset  should  not  be  confused  with  habitual  vomiting,  since 
the  treatment  differs  greatly. 

It  may  be  subdivided  according  to  cause  into 

(a)  Acute  indigestion  caused  by  indigestible  food  unfit 
for  the  infant. 

(fc)  Acute  infectious  gastro-enteritis. 

(c)  Miscellaneous  causes:  General  infectious  diseases 
such  as  pneumonia,  acute  exanthemata,  etc.,  peritonitis, 
intestinal  obstruction,  nephritis,  cerebral  vomiting  from 
meningitis,  brain  tumor,  etc.,  drugs  and  poisons. 

Only  the  first  and  second  varieties  of  acute  vomiting  will 
be  discussed  here,  since  the  others  should  receive  treatment 
appropriate  for  the  cause  upon  which  they  depend.  These 
two  classes  of  vomiting  are  usually  easy  to  control  and  are, 
in  fact,  often  self -limited,  and,  since  they  both  are  amenable 
to  the  same  treatment,  it  is  not  necessary  to  discuss  each 
separately. 

184 


VOMITING  IN  BOTTLE-FED  INFANTS         185 

TREATMENT  OF  ACUTE  VOMITING 

(1)  Stop  food  and  water          (3)  Empty  the  bowels 

(2)  Give  sodium  bicarbonate     (4)  Wash  out  the  stomach 

by  mouth  (5)  Administer  sedatives 

(1)  Stop  Food  and  Water. — Often  the  chief  reason  why 
acute  vomiting  is  difficult  to  control  is  because  the  stomach 
is  not  given  a  rest  from  food  and  water.    Mothers  are  very 
apt  to  make  this  error,  believing  that  nourishment  is  the 
essential  part  of  any  treatment,  even  in  the  beginning  of 
an  illness. 

Do  not  allow  anything  by  mouth,  even  water,  for  a  few 
hours.  This  is  a  hard  rule  to  follow,  as  the  older  infants 
and  children  suffer  intensely  from  thirst  and  often  beg 
piteously  for  water.  If  allowed  to  quench  their  thirst  with 
a  glass  of  water,  it  is  immediately  vomited  and  the  thirst 
is  as  great  as  ever.  The  water  satisfies  for  a  moment  only 
and  aggravates  the  vomiting. 

(2)  Give   Sodium  Bicarbonate  by   Mouth. — After  a  few 
hours  of  abstinence  from  water,  sodium  bicarbonate,  one 
level  teaspoonful  to  a  glass  of  water,  may  be  used,  giving 
one  tablespoonful  of  this  solution  every  fifteen  minutes  or 
half  hour.    This  is  very  effective  in  acute  vomiting,  particu- 
larly in  older  infants,  and,  except  in  most  resistant  cases, may 
be  greatly  relied  upon  to  relieve  the  trouble.    If  a  table- 
spoonful  is  retained,  the  amount  may  be  increased,  a  table- 
spoonful  at  a  time,  until  two  or  three  ounces  are  taken 
without  causing  vomiting.    As  the  quantity  is  increased  it 
should  be  given  at  longer  intervals,  perhaps  once  an  hour. 
After  there  has  been  no  vomiting  for  ten  or  twelve  hours, 
it  is  safe  to  try  water  without  sodium  bicarbonate,  beginning 
with  small  quantities  at  first.    If  this  is  well  borne,  a  very 
dilute  food  may  be  started.    Infants  under  six  months  of  age 
usually  take  one-third  milk  and  two-thirds  water,  beginning 
wTith  only  two  or  three  ounces  at  a  feeding,  and  are  fed  once 


186  SIMPLIFIED  INFANT  FEEDING 

in  three  hours.  With  infants  between  six  months  and  a  year 
it  is  best  to  try  a  weak  barley  gruel  first,  about  a  tablespoon- 
ful  of  barley  flour  to  a  pint  of  water.  If  this  is  not  vomited, 
and  provided  there  is  no  centra-indication  in  the  condition  of 
the  bowels,  weak  milk  feedings  may  be  instituted  after 
twelve  or  eighteen  hours.  Infants  over  a  year  of  age,  and 
particularly  those  who  are  not  bottle-fed,  may  be  fed  a  clear 
broth  or  bouillon,  well  heated,  beginning  with  a  tablespoon- 
ful  at  a  time,  or  a  malted  milk  mixture  made  with  two 
heaping  teaspoonfuls  of  malted  milk  to  four  ounces  of 
water.  Boiled  skimmed  milk  and  water,  in  equal  parts, 
may  be  retained  in  the  most  persistent  cases. 

Although  a  period  of  abstinence  from  food  is  advisable 
and  of  great  benefit  at  the  beginning  of  vomiting,  one  occa- 
sionally sees  infants  that  have  been  deprived  of  food  too  long 
in  an  attempt  to  stop  obstinate  vomiting.  After  a  twenty- 
four-hour  abstinence  from  food,  or  starvation,  it  is  well  to 
try  one  of  the  foods  above  suggested,  because  the  vomiting 
may  then  often  be  stopped  by  giving  the  stomach  something 
to  work  upon. 

(3)  Empty  the  Bowels. — At  the  beginning  of  an  attack 
of  acute  vomiting  one  of  the  first  things  to  do  is  to  see  that 
the  gastro-intestinal  tract  is  empty  of  any  harmful  contents. 
Unfortunately,  cathartics  are  not  easily  retained  and  may 
even  excite  or  increase  the  vomiting.  For  this  reason  it  is 
best  to  give  an  enema  first,  using  either  soapsuds  or  glycerine 
and  water.  If  a  good  evacuation  is  not  obtained  in  this  w^ay, 
magnesium  sulphate,  half  an  ounce  to  four  ounces  of  water, 
may  be  given  by  rectum,  allowing  it  to  be  retained  as  long 
as  possible.  If  the  fever  is  high,  it  may  be  necessary  to  give 
some  cathartic  by  mouth.  Calomel  has  formerly  been  the 
cathartic  of  choice,  especially  for  acute  vomiting,  but  the 
author  seldom  uses  it  now  as  it  seems  to  act  as  an  irritant  to 
the  stomach.  How  often  do  we  give  divided  doses  of  calomel 
to  a  child  that  is  not  vomiting,  and  after  a  few  doses  the  most 
persistent  emesis  results!  Castor  oil,  if  given  early  or  as 
soon  as  the  stomach  has  been  emptied  of  food,  is  the  cathartic 


FIG.  7. — Inserting  the  tube  for  stomach  washing. 


Fio.  8. — Pouring  in  the  water  for  stomach  washing 


r— Emptying  the  stomach. 


VOMITING  IN  BOTTLE-FED  INFANTS        187 

of  choice.  Give  a  moderately  small  dose  and  repeat  in  one- 
half  hour  if  it  is  vomited  or  in  two  hours  if  not  vomited  and 
the  bowels  have  not  moved.  Two  teaspoonfuls  may  be  given 
to  an  infant  under  six  months  of  age,  and  one  tablespoonful 
to  an  infant  over  six  months.  It  is  best  to  avoid  cathartics 
in  severe  infectious  diarrhoea,  particularly  bloody  diarrhoea, 
if  the  bowels  have  already  been  evacuated  thoroughly  and 
the  stools  contain  no  undigested  food  or  fecal  matter. 

(4)  Wash  out  the  Stomach  Once.— (See  "Lavage.")     If 
the  result  with  one  washing  is  not  successful,  it  is  not  de- 
sirable to  repeat  the  process,  as  the  second  effort  will  not  be 
any  more  successful  than  the  first.    A  great  deal  of  harm 
has  been  done  by  too  frequent  washing  of  the  stomach. 

(5)  Sedatives  will  often  do  a  great  deal  of  good  when 
the  stomach  has  become  so  irritable  that  the  vomiting  can- 
not be  stopped  in  any  other  way,  particularly  in  cases  of 
severe  dysentery  and  cholera  infantum.    They  should  not 
be  used  until,  through  constant  vomiting  and  purging,  the 
stomach  and  bowels  have  been  cleared  of  all  the  material 
that  is  causing  the  disturbance,  nor  should  they  be  used 
when  there  is  stupor  or  coma.    Children  over  a  year  of  age 
may  have  a  single  dose  of  phenacetin  by  mouth.    When  so 
given  in  single  doses,  phenacetin  is  not  the  formidable  drug 
that  we  have  been  led  to  fear.     One  or  two  grains  of  the 
powder  moistened  with  a  teaspoonful  of  water  may  be  given 
quite  harmlessly. 

Paregoric  is  an  extremely  useful  drug  in  selected  cases 
of  severe  vomiting.  The  only  objection  to  its  use  is  that  it 
is  not  of  uniform  strength,  and  care  must  be  taken  to  pro- 
cure the  official  preparation.  It  should  not  be  used  until 
the  bowels  and  stomach  have  been  thoroughly  emptied,  nor 
where  there  is  stupor  or  coma.  Its  beneficial  effect  in  con- 
trolling vomiting  is  due  to  its  sedative  action  upon  the 
irritable  stomach  and  to  its  general  effect  as  an  opiate.  It 
should  never  be  given  in  large  enough  doses  to  produce  sleep 
so  profound  that  the  infant  cannot  be  awakened  for  its  food. 


188  SIMPLIFIED  INFANT  FEEDING 

It  is  usually  safe  to  give  an  infant  of  any  size  two  drops 
every  four  hours,  preferably  before  a  feeding.  The  dose  may 
be  increased  to  two  or  four  drops  every  two  hours,  provided 
the  vomiting  is  not  controlled  by  the  smaller  dose  and  pro- 
vided the  infant  wakes  at  regular  intervals  for  its  feedings 
and  takes  them  well. 

Young  infants  or  older  ones  who  are  not  helped  by  the 
phenacetin  or  paregoric,  particularly  in  severe  dysentery 
or  cholera  infantum,  may  have  subcutaneously  morphine, 
gr.  ^T,  combined  with  atropine,  gr.  ^.  A  single  dose  only 
should  be  given. 

CASK  XL, 

I 

(Illustrating  treatment  of  acute  vomiting) 

August  1:     Age,  9  months.     Weight,  19  Ib.  8  oz. 

General  Condition. — Well  nourished  and  developed,  high  color,  restless. 
Stools. — One  normal  a  day  until  onset;  since  then  none. 
Vomiting. — Sudden  onset  eight  hours  ago,  consisting  first  of  food;   since  then 

only  bile-stained  water.    Has  vomited  every  fifteen  minutes  since  onset. 
Appetite. — Water  taken  greedily. 
Sleep. — Has  cried  almost  continuously  since  onset. 
Temperature,  104°  F. 
Previous  Food. — Has  been  properly  bottle-fed  since  birth.    Yesterday  went  on 

an  all-day  trip  to  the  seashore,  the  milk  being  carried;  possibly  irrational 

food  was  eaten.    Since  onset  only  water  has  been  given. 
Treatment. — Castor  oil,  one  tablespoonful.    Repeat  in  a  half  hour  if  vomited. 

Give  one  tablespoonful  of  a  sodium  bicarbonate  solution    (one  teaspoonful 

to  eight  ounces  of  water )  every  half  hour,  gradually  increasing  the  quantity 

if  the  vomiting  stops.    Food  prescribed:  Nothing  allowed  by  mouth  (not  even 

water)   except  sodium  bicarbonate  solution. 

August  2  ( 1  day  later )  : 

General  Condition. — Quiet,  contented. 

Stools. — Six  green  stools  containing  undigested  curds,  small  amount  of  mucus. 

Vomiting. — Stopped  after  three  or  four  hours. 

Appetite. — Takes  the  sodium  bicarbonate  water,  three  or  four  ounces  at  a  time. 

Sleep. — Good  throughout  the  night. 

Temperature,  98.6°  F. 

There  was  no  recurrence  of  the  vomiting  when  small  amounts  of  a  weak 
food  were  allowed  and  gradually  increased  to  the  usual  formula. 

Castor  oil  one  tablespoonful.    Repeat  in  */£  hour  if  vomited. 


VOMITING  IN  BOTTLE-FED  INFANTS        189 

CASE  XLI 

(Illustrating  the  use  of  paregoric  for  aevere  vomiting  of  three  weeks'  duration) 
July  17:  Age,  18  months.  Weight,  13  Ib.  8  or. 

General  Condition. — Has  become  rapidly  emaciated  in  the  last  three  weeks,  pale, 
in  a  condition  of  collapse,  eyes  sunken,  extremely  weak,  apathetic,  feeble 
cry,  feet  and  hands  cold. 

Stools. — Small,  green,  mucous,  very  little  fecal  matter  (with  an  enema  of 
soapsuds)  twice  a  day.  Has  never  had  any  diarrhoea. 

Vomiting. — Three  weeks  ago,  sudden  onset,  previously  well;  vomited  many 
times  the  first  day;  since  then,  up  to  the  present  time,  has  vomited  almost 
everything  taken  by  mouth,  even  water  at  times,  causing  the  rapid  emacia- 
tion, loss  of  strength,  and  small  mucous  stools. 

Appetite. — Took  liquids  greedily  until  the  last  two  days;  since  then  will  take 
very  little.  . 

Sleep. — Only  fifteen  minutes  at  a  time,  night  or  day,  since  onset. 

Temperature,  101°  F. 

Chief  Complaint. — Vomiting. 

Previous  Food. — Breast-fed  the  first  year  and  did  very  well.  For  the  last  six 
months,  in  addition  to  the  bottle,  has  received  an  irrational,  irregular  diet 
of  solid  food.  Since  onset  has  had  clear  broth,  fruit  juices,  white  of  egg  in 
water,  crackers. 

Treatment. — Paregoric,  two  mm.  every  four  hours  in  one  teaspoonful  of  water 
(given  immediately  before  a  feeding),  to  be  increased  to  two  or  even  three 
drops  every  two  hours  if  the  vomiting  is  not  controlled.  Strychnia,  gr.  */»• 
every  four  hours  before  feedings.  Stop  soapsuds  enemas;  give  enema  of  plain 
water  once  in  36  hours  if  the  bowels  do  not  move  of  their  own  accord. 

Food  prescribed: 

Skimmed    milk  and  water,  equal      Feed   1%   oz.  every  2  hours,   12 
parts,  boiled,  without  sugar.  feedings  in  24  hours. 

July  18  (1  day  later): 
General  Condition. — Slightly  improved. 
Stools. — Bowels  have  not  moved. 
Vomiting. — Only  once  since  last  visit. 
Appetite. — Takes  food  well. 
Sleep. — Better. 

Treatment. — The  paregoric  having  been  increased  to  three  drops  every  two 
hours,  is  now  decreased  to  two  drops  every  two  hours.  Strychnia  continued. 

Food  prescribed: 

Skimmed    milk  and  water,  equal      The  quantity  at  each  feeding  to  be 
parts,  boiled,  without  sugar.  increased  l/2  oz.  at  a  time  up  to 

3  oz.  every  two  hours,  12  feed- 
ings in  24  hours. 


190  SIMPLIFIED  INFANT  FEEDING 

July  19   (1  day  later): 

General  Condition. — Much  improved. 

Stools. — One  with  enema. 

Vomiting. — None  since  last  visit. 

Appetite. — Takes  three  ounces  slowly  but  well  every  two  hours. 

Sleep. — Most  of  the  time  between  feedings. 

Treatment. — Paregoric  decreased  to  two  drops  every  four  hours.     Strychnia 

decreased  to  gr.  ^/^  every  four  hours. 

Food  prescribed: 

Add  one  ounce   of  top  milk   taken   from   the   quart   to   the   remaining- 

skimmed  milk  left  in  the  quart  bottle.     Using  this  milk,  make  the  food: 

Skimmed  milk  ...   2  oz.  |       .   .       Feed  3  oz.  every  2  hours.  12  feed- 
Water  1  oz.  J  ings  in  24  hours. 

Sugar 0 

July  21   (2  days  later)  : 

Qeneral  Condition. — Much  improved,  eyes  no  longer  sunken,  still  weak. 
Stools. — One  voluntary. 
Vomiting. — None. 

Appetite. — Takes  all  the  food  offered. 
Sleep. — A  great  deal. 
Treatment. — Paregoric  discontinued.    Strychnia,  gr.  y400  every  four  hours. 

Food  prescribed: 

Each  night  and  morning  add  one     Feed  4  oz.  every  3  hours,  8  feed- 
more  ounce  of  the  top  milk  to         ings  in  24  hours, 
the    full    amount    of    skimmed 
milk    contained    in    the   quart, 
until  full  milk  is  used.    Give 
this  milk  undiluted. 

This  patient,  seen  in  consultation,  was  not  under  the  author's  direct 
observation  after  this  period,  but  an  eventual,  although  slow,  recovery  took 
place. 

This  was  a  case  of  acute  vomiting  of  three  weeks'  duration,  and  food  was 
very  much  needed.  The  boiled  skimmed  milk  and  water  was  easily  retained 
when  the  gastric  irritability  was  overcome  by  paregoric.  The  infant  was  sa 
weak  that  it  was  also  in  great  need  of  stimulation,  and  the  strychnia  was  there- 
fore begun.  The  bowels  had  not  moved  previous  to  the  first  visit  because  there 
was  no  residue,  practically  no  food  having  passed  into  the  intestines.  It  is  a 
mistake  to  give  soap  and  water  and  other  irritating  enemas  or  irrigations  in 
euch  cases. 


VOMITING  IN  BOTTLE-FED  INFANTS         191 

HABITUAL  VOMITING 

Habitual  vomiting  is  a  term  applied  to  vomiting  which 
occurs  every  day  for  at  least  a  week  and  often  for  many 
weeks.  Vomiting  is  not  habitual  unless  it  occurs-  after  many 
or  all  the  feedings. 

Mothers  are  prone  to  exaggerate  the  importance  of 
spitting  up  of  a  mouthful  or  two  after  the  feeding,  so  that 
the  physician  must  ascertain  how  much  in  quantity  is  vom- 
ited, how  many  times  a  day  it  occurs,  and  whether  it  occurs 
immediately  after  a  feeding  or  just  before,  or  continuously 
throughout  the  interval;  and  it  is  also  well  to  ascertain 
whether  the  vomiting  is  projectile  in  character  or  not.  Other 
things  being  equal,  the  more  food  vomited  and  the  shorter 
the  intervals,  the  more  severe  is  the  gastric  indigestion. 
Vomiting  that  occurs  just  before  a  feeding  time  indicates 
that  the  gastric  digestion  is  very  much  retarded  or  that  the 
feedings  are  given  too  near  together;  vomiting  that  occurs 
immediately  after  a  feeding  only  is  of  much  less  serious 
import,  provided  the  quantity  is  not  large.  When  all  of  the 
food  is  vomited  at  once,  a  few  minutes  after  it  is  taken,  and 
with  such  force  that  it  is  projected  a  distance  of  three  or  four 
feet,  it  may  be  considered  as  projectile  vomiting.  This  form 
is  seen  in  pyloric  stenosis,  meningitis,  and  in  cases  of 
intracranial  pressure  from  other  causes. 

Causes  of  Habitual  Vomiting. — Habitual  vomiting  in  bottle- 
fed  infants  may  be  caused  by 

(1)  Errors  in  the  details  of  administering  the  food,  such 
as  irregular  feeding,  etc.  (to  be  enumerated  later). 

(2)  Indigestion  from  fat,  sugar,  starch,  or  overfeeding. 

(3)  Overfeeding  in  quantity. 

(4)  The  hypertonic  infant. 

(5)  Organic  causes :    Pyloric  spasm  or  stenosis,  dilata- 
tion of  the  stomach,  gastroptosis,  reflex  vomiting. 

An  infant  may  have  a  combination  of  many  or  all  of  these 


192  SIMPLIFIED  INFANT  FEEDING 

causes,  so  that  it  is  not  possible  to  divide  the  treatment  into 
different  methods.  All  cases  must  be  looked  into  carefully 
and  any  of  the  above  errors  rectified  if  present. 

(1)    EBBORS  IN  DETAIL  OF  ADMINISTERING  THE  FOOD 

The  following  are  apt  to  be  common  mistakes  made  in 
the  feeding  of  infants : 

(a)  Too  rapid  feeding. 

(b)  Too  slow  feeding. 

( c)  Feeding  in  a  reclining  position  and  leaving  the  infant 
to  take  the  bottle  alone. 

(d)  Not  allowing  the  air  swallowed  during  the  nursing 
to  be  eructated  before  the  feeding  is  complete  by  occasionally 
holding  the  infant  in  an  upright  position. 

(e)  Too  long  a  nipple  which  gags  the  infant. 

(/)  Tossing  the  infant  about  or  handling  it  too  soon  after 
feeding. 

(g)  Tight  belly-band  and  clothing. 

(a)  Too  rapid  feeding  is  a  detail  that  has  been  dwelt  upon 
a  great  deal,  and  perhaps  its  importance  has  been  somewhat 
exaggerated.    It  is  best  to  have  a  small  infant  take  fifteen 
or  twenty  minutes  for  a  feeding,  and,  as  this  is  difficult  to 
accomplish  in  a  very  hungry  baby  whose  feedings  have  been 
cut  down  on  account  of  digestive  disturbances,  a  nipple  with 
an  extremely  small  hole  must  be  used.    The  mother  should 
be  instructed  to  select,  from  a  large  assortment,  a  nipple 
which  has  a  hole  so  small  that  when  held  in  front  of  the  eye 
the  light  can  scarcely  be  seen  through  it. 

(b)  The  error  of  feeding  too  slowly  is  usually  not  suffi- 
ciently emphasized.    Many  weak,  small  infants  are  given 
a  nipple  with  too  small  a  hole  and  are  allowed  to  nurse  for 
one-half  or  three-quarters  of  an  hour,  or  sometimes  even 
an  hour,  before  the  food  is  taken.    If  such  an  infant  is  fed 
every  two  hours,  it  may  be  nursing  almost  twelve  hours  out 


FIG.  10. — Correct  way  to  give  a  bottle  feeding. 


VOMITING  IN  BOTTLE-FED  INFANTS        193 

of  every  twenty-four.  This  may  seem  an  exaggerated  state- 
ment, but  one  who  does  much  infant  feeding  occasionally 
finds  such  instances.  In  such  cases  a  nipple  with  a  larger 
hole  should  be  used.  The  hole  should  be  large  enough  to 
allow  the  food  to  drop  out  freely  when  the  bottle  is  turned 
upside  down.  The  bottle  should  be  given  to  the  infant  for 
twenty  minutes  only,  and  all  that  is  not  taken  in  that  time 
should  be  discarded,  no  more  food  being  allowed  until  the 
next  feeding,  when  a  fresh  bottle  is  given. 

Slow  feeding  also  permits  the  infant  to  swTallow  air,  and 
later,  because  the  stomach  is  distended,  the  food  is  ejected 
instead  of  the  air. 

(c)  Feeding  in  a  reclining  position  and  leaving  the  infant 
to  take  the  bottle  alone  is  another  mistake.    The  most  natural 
way  for  an  infant  to  take  the  bottle  is  in  a  semi-upright  posi- 
tion, because  that  is  the  usual  and  proper  manner  of  feeding 
from  the  breast.   When  an  infant  is  held  in  the  lap  the  prog- 
ress of  every  detail  may  be  observed :  how  fast  the  food  is 
being  taken,  whether  it  is  all  being  taken,  and  whether  the 
baby  is  swallowing  air. 

(d)  Not  allowing  the  air  to  be  eructated  while  the  baby  is 
in  an  upright  position  is  another  error.     X-ray  plates  of 
infants  taken  after  a  feeding  always  show  an  air  bubble  in 
the  stomach.     If  these  pictures  are  taken  in  an  upright 
position,  the  air  space  is  over  the  cardiac  end  of  the  stomach. 
If  they  are  taken  in  a  horizontal  position,  the  air  space  is 
seen  elsewhere,  but  usually  not  near  the  oesophagus.    It  is 
obvious  that  when  the  infant  is  in  an  upright  position  the 
air  is  eructated  instead  of  the  food.     For  this  reason  an 
infant  who  is  vomiting  right  after  a  feeding,  should  be  put 
upon  the  mother's  shoulder  three  or  four  times  during  the 
feeding  and  patted  upon  the  back  until  the  air  comes  up. 
This  is  an  expedient  which  many  mothers  have  learned  to 
use  of  their  own  accord,  and  one  frequently  sees  the  vomit- 
ing stopped  at  once  in  this  way. 

13 


194  SIMPLIFIED  INFANT  FEEDING 

(e)  Too  long  a  nipple  which  gags  the  baby  is  liable  to 
cause  vomiting  of  all  the  food  taken.  It  usually  occurs  at  the 
end  of  the  nursing  and  only  once  or  twice  a  day,  or  even  less 
frequently. 

(/)  Tossing  the  baby  about  or  handling  too  soon  after  a 
feeding  has  long  been  recognized  as  a  source  of  vomiting. 

(ff)  Tight  belly-bands  undoubtedly  cause  vomiting.  The 
infant  strains  and  wriggles  about  with  the  feeling  of  dis- 
tention  which  comes  after  feeding,  and  the  belly-band  helps 
the  abdominal  muscles  to  force  the  food  through  the  cardiac 
end  of  the  stomach  instead  of  the  pylorus.  The  belly-band, 
therefore,  should  be  discarded  in  all  infants  who  are  vomiting 
badly.  If  the  band  is  worn  to  correct  a  weak  navel  or  one 
which  shows  any  signs  of  hernia,  a  small  piece  of  adhesive 
plaster  strapped  over  the  umbilicus  may  be  substituted. 

(2)  INDIGESTION  FROM  FAT,  SUGAR  AND  STARCH 

A  very  useful  method  of  treating  habitual  vomiting  is 
that  of  feeding  one-third  milk  and  two-thirds  water,  boiled 
together  with  no  sugar  or  a  small  amount  of  sugar.  For- 
tunately the  same  treatment  is  useful  in  many  cases  of  diar- 
rho3a.  Even  if  there-  is  fat  indigestion,  the  small  amount  of 
fat  remaining  in  whole  milk  diluted  three  times  will  rarely 
do  any  harm.  An  exception  to  this  statement  is  illustrated 
in  the  case  preceding.  When  the  vomiting  is  very  severe  and 
nothing  has  been  retained  over  a  long  period,  boiled  skimmed 
milk  and  water  without  sugar  is  more  apt  to  be  well  borne. 
Later  the  cream  taken  from  the  top  of  the  bottle  of  milk 
may  be  gradually  added  to  the  skimmed  milk  until  full  milk, 
properly  diluted,  is  used. 

If  the  vomiting  is  due  to  sugar,  it  is  easily  controlled 
by  stopping  the  artificial  sugar  altogether.  Undoubtedly 
sugar  is  the  greatest  source  of  gastric  indigestion,  as,  when 
once  under  control,  increasing  the  strength  of  the  milk 
rarely  causes  the  vomiting  to  return,  while  a  too  rapid 


VOMITING  IN  BOTTLE-FED  INFANTS        195 

increase  in  sugar,  or  increasing  the  sugar  to  too  great  a 
quantity  in  the  twenty-four-hour  amount,  very  often  causes 
a  recurrence. 

If  starch  indigestion  is  present,  the  vomiting  is  stopped 
by  diluting  the  milk  with  water  instead  of  gruels,  and  the 
author  has  seen  many  young  infants  who  continued  to  vomit 
until  this  was  done. 

Boiling  the  milk  makes  it  less  coagulable, — that  is,  retards 
coagulation  in  the  stomach.  It  also  changes  some  of  the 
milk  sugar  into  caramel,  which  is  more  innocuous  than 
lactose.  _  YT  TT 

CASE  XLII 

(Illustrating  habitual  vomiting  controlled  by  regulating  the  amount  of  sugar 
and  the  intervals  of  feeding) 
December  29:     Age,  3  months  2  weeks.     Birth  weight,  5  Ib. 

Present  weight,  7  Ib.  7  oz. 
General    Condition. — Very    poorly    nourished,    pale,    poor    musculature,    head 

asymmetrical  and  other  signs  of  rickets,  cries  vigorously.    Needs  from  60  to 

65  calories  per  pound  per  day. 

Stools. — One  normal  stool  with  a  teaspoonful  of  castor  oil  every  night. 
Vomiting. — Has  vomited  more  or  less  since  birth.    For  the  last  few  weeks  has 

vomited  a  great  deal  after  each  feeding  and  throughout  the  intervals  between 

feedings. 

Appetite. — Poor;  leaves  half  of  a  feeding  two  or  three  times  a  day. 
Sleep. — Poor;  cries  three  hours  during  the  night  and  a  great  deal  during  the 

day. 

Temperature,  98.6°  F. 
Chief  Complaint. — Vomiting. 
Previous  Food. — Bottle-fed  since  birth,  various  foods  the  first  six  weeks;  since 

then  the  following  formula,  the  quantity  of  milk  and  sugar  being  occasion- 
ally changed: 

Milk 10  oz.-»  200  cals.  Fed  3y2  oz.  every  2  hours,  10  feed- 
Water  24  oz.  j  ings  in  24  hours,  not  all  taken. 

Malt  sugar 2  oz.  240  cals. 

440  calories,  or  59-  calories  per  pound. 

Treatment. — Stop  giving  castor  oil,  and  give  an  enema  once  a  day  if  the  bowels 
will  not  move  without  it. 
Food  prescribed: 

Milk 12  oz.~>  ,         Divide  into  7  bottles.     Feed  4-f 

Water 18  oz.  j  oz.  every  3  hours  at  6,  9,   12 

Dextri-maltose  . .  %  oz.  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 


196  SIMPLIFIED  INFANT  FEEDING 

Each  day  increase  the  milk  one  ounce  and  decrease  the  water  the  same 
amount  up  to 

Milk     15  oz.  |       .        300  cals. 

Water    15  oz.  f 

Dextri-maltose   *4  oz.  30  cals, 

330  cals.,  or  44  calories  per  pound. 

January  6  (8  days  later)  :     Weight,  7  Ib.  5  oz. 

Loss,  2  oz. 

General  Condition. — As  at  last  visit. 
Stools. — One  hard  with  enema. 
Vomiting. — A  little  after  each  feeding. 
Appetite. — Excellent,  all  the  food  taken. 
Sleep. — Better. 

Treatment. — Food  prescribed : 

Milk 15  oz.  )  ...   ,  300  calories  Divide  into  7  bottles.  Feed  4+  oz. 

v  boiled 
Water 15  oz.  J  every  3  hours  as  before. 

Dextri-maltose  .   %  oz.  90  calories 

(by  gradual  increase) 

390  calories,  or  53-  calories  per  pound. 

January  14  (8  days  later)  :     Weight,  7  Ib.  9  oz. 

Gain,  4  oz. 

General  Condition. — Improved. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Poor. 

Treatment. — Food  prescribed: 

Milk 16  oz. }  ,.,,  32°  calories      Divide  into  7  bottles.    Feed  4% 

Water 16  oz.  J  oz.  every  3  hours  as  before. 

Dextri-maltose  .     1  oz.  120  calories 


440  calories,  or  59  calories  per  pound. 

January  21  (7  days  later).     Weight,  8  Ib.  1  oz. 

Gain,  8  oz. 

General  Condition. — Improved. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Good. 
Bleep. — Good. 


VOMITING  IN  BOTTLE-FED  INFANTS        197 

Treatment . — Food  prescribed : 

Milk 18  oz.)  ,         ,   360  calories       Divide  into  7  bottles.    Feed  5+ 

«T  .L  ^boiled 

Water 18  oz.  j  oz.  every  3  hours. 

Dextri-maltose  .      1  oz.  120  calories 


480  calories,  or  60-  calories  per  pound. 

At  the  first  visit  there  were  both  lack  of  appetite  and  a 
great  deal  of  gastric  indigestion  caused  by  the  large  quan- 
tity of  sugar.  It  was.  not  necessary  to  stop  the  sugar 
altogether,  which  is  often  the  case  in  infants  who  have  been 
given  excessive  amounts  of  sugar.  Two  ounces  of  sugar 
in  twenty-four  hours  for  a  T^-pound  infant  is  far  too  much, 
whether  there  is  vomiting  or  not.  It  was  thought  advisable 
at  the  first  to  lengthen  the  intervals  from  two  to  three  hours, 
since  the  vomiting  was  almost  continuous  and  occurred 
immediately  before  a  feeding  was  due.  It  will  be  seen  that 
the  vomiting  was  very  much  diminished  in  eight  days,  and 
a  week  later  had  stopped  altogether.  The  appetite  improved 
at  the  same  time. 

One  must  be  always  on  his  guard  not  to  allow  a  very 
weak,  emaciated  infant  to  remain  too  long  upon  a  weak  milk 
and  water  diet,  containing  no  sugar.  If  such  an  infant 
loses  rapidly  in  weight,  he  may  die  from  the  lack  of  food 
and  from  loss  of  body  fluids.  If  this  rapid  drop  in  weight 
or  collapse  occurs,  the  vomiting  must  be  disregarded  and 
half  an  ounce  of  sugar  added  at  once  to  the  twenty-four- 
hour  amount.  The  sugar  will  cause  water  retention  within 
the  body  and  an  immediate  gain  in  weight,  and  thus  help  to 
tide  the  infant  over  a  critical  period. 

CASE  XLIII 
(Illustrating  the  danger  of  omitting  the  sugar  in  a  weak  infant) 

February  27:     Age,  4  months  1  week.     Birth  weight,  4  Ib.  5  oz. 

Present  weight,  6  Ib. 
General  Condition. — Extremely  emaciated,  pale,  apathetic,  feeble  cry.     Needs 

from  60  to  65  calories  per  pound  per  day. 
Stools. — Constipated  since  birth;  one  hard  stool  with  glycerine  suppository. 


198 

Vomiting. — Since  birth,  large  quantities  throughout  the  intervals  between  feed- 
ings; never  projectile.  Almost  all  of  the  feeding  ejected. 

Appetite. — 'Ravenous;  takes  water  between  feedings. 

Sleep. — Poor;  cries  night  and  day. 

Temperature,  98.6°  F. 

Chief  Complaint. — Vomiting,  emaciation. 

Previous  Food. — Nursed  mother's  breast  for  the  first  six  weeks  of  life,  when 
a  wet  nurse  was  secured  for  six  weeks.  During  the  period  of  wet  nursing 
the  child  gained  one  pound  and  twelve  ounces,  but  on  account  of  the  vomiting 
the  wet  nurse  was  unwisely  discontinued.  Since  then  various  proprietary 
foods  were  used,  and  for  the  last  two  weeks: 

Buttermilk  boiled  with  rice  flour      2  oz.  every  2  hours,  10  feedings 

in  24  hours. 


Treatment. — Food  prescribed : 

Milk   8  oz.  )  .             Divide  into  10  bottles.    Feed  2  oz. 

Water  24  oz.  j  every  2  hours.     Increase  %  oz. 

Sugar 0  a  day  up  to  3  oz.  at  a  feeding. 


Since  the  patient  lived  a  hundred  miles  out  of  town  and  could  be  seen 
but  once  a  week,  directions  were  given  to  put  one  teaspoonful  of  malt  sugar 
in  the  food  in  two  days,  whether  the  vomiting  had  stopped  or  not.  In  two 
more  days  the  sugar  was  to  be  increased  to  two  teaspoonfuls,  and  the  patient 
was  to  return  in,  one  week.  These  directions  were  not  obeyed  for  fear  of  a 
return  of  the  vomiting,  as  the  baby  had  never  before  vomited  as  little  as  it 
did  on  this  boiled  milk  and  water  diet.  When  the  infant  was  brought  to  the 
office  a  week  later  this  failure  to  carry  out  directions  in  regard  to  the  sugar 
resulted  in  the  loss  of  weight  and  general  condition  indicated  below. 

March  5    (7  days  later)  :     Weight,  5  Ib.  3  oz. 

Loss,  13  oz. 

General  Condition. — Too  weak  even  to  move  head  from  side  to  side,  eyes  sunken, 
loss  in  weight  of  13  ounces  during  the  week.  This  condition  was  due  to  the 
error  of  keeping  the  infant  so  long  on  a  weak  food  without  any  sugar  when 
emaciation  was  already  marked. 

Stools. — One  hard,  dry  stool  (with  suppository). 

Vomiting. — Much  better,  vomits  only  a  mouthful  occasionally. 

Appetite. — Good;  takes  three  ounces  at  a  feeding. 

Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk    10  oz.  )  Divide  into  10  bottles.       Feed  3  oz. 

Water   20  oz.  j  b                    every  2  hours,  at  6,  8,  10,  12  A.M., 

Dextri-maltose. . .   ya  oz.  2,  4,  6,  8,  10  P.M.,  and  2  A.M. 

March  8    (3  days  later):     Weight,  5  Ib.  8  oz. 

Gain,  5  oz. 


VOMITING  IN  BOTTLE-FED  INFANTS       199 

General  Condition. — Much  improved. 
Stools. — One  hard,  dry. 
Vomiting. — Little. 
Sleep. — Good. 

Treatment. — Food  prescribed: 


Milk  ...........    12  oz.  )       .         240  calories      Divide  into  10  bottles.    Feed 

Water  ...........    18  oz.  f  **"•"  3  oz.  every  2  hours,  as  be- 

Dextri-maltose   .  .    %  oz.  60  calories          fore. 


300  calories,  or  55-  calories  per  pound. 

March  12   (4  days  later)  :     Weight,  5  Ib.  13  oz. 

Gain,  5  oz. 

General  Condition.  —  Still  more  improved. 
Stools.  —  One  hard,  dry. 
Vomiting.  —  Little. 
Appetite.  —  Good. 
Sleep.  —  Good. 

Treatment.  —  Food  prescribed  : 

Milk  ...........    14  oz.  )  280  calories      Feed  3  oz.  every  two  hours 

Water  ...........    16  oz.  [  b  as  before,    10  feedings  in 

Dextri-maltose   .  .    %  oz.  90  calories          24  hours. 

370  calories,  or  63-  calories  per  pound. 
March  20  (8  days  later)  :     Weight,  6  Ib.  4  oz. 

Gain,  7  oz. 

General  Condition.  —  Still  more  improved. 
Stools.  —  Two  normal  without  enema. 
Vomiting.  —  None, 
Appetite.  —  Good. 
Sleep.  —  Good. 

Treatment.  —  Food  prescribed  : 

Milk    ...........    15  oz.  )  300  calories      Feed  3  oz.  every  2  hours,  10 

v    nrnlPn 

Water  ...........    15  oz.  j  "  feedings  in  24  hours  as  be- 

Dextri-maltose   .  .   %  oz.  90  calories          fore. 

390  calories,  or  63-  calories  per  pound. 

With  the  exception  of  one  brief  period  when  there  was  no  gain  in  weight, 
this  infant  gained  progressively  and  never  vomited  again  to  any  extent. 

The  above  description  cannot  do  justice  to  the  remarkable  improvement 
occurring  in  an  infant  that  was  almost  moribund  at  the  second  visit. 


200 

Dry  milk  is  well  borne  in  vomiting  cases  caused  by 
indigestion  from  fat,  sugar  and  starch.  It  is  low  in  fat,  no 
artificial  sugar  need  be  added  to  it  at  first,  and  the  proteid  is 
more  easily  digested  than  even  the  proteid  of  boiled  milk. 
The  following  case  illustrates  its  use : 

CASE  XLIV 

(Illustrating  the  use  of  Dry  Milk  in  vomiting) 
December  23:     Age,  2  months.     Weight,  9  Ib.  4  oz. 

Birth  weight,  10  Ib. 
Loss  since  birth,  12  oz. 
General  Condition. — Pale,  emaciated. 
Stools. — One  small,  constipated  with  enema. 
Vomiting. — Beginning  at  three  weeks  of  age  and  increasing  in  frequency  and 

quantity.     Lately  only  a  small  portion  of  food  retained. 
Appetite. — Ravenous. 
Sleep. — Cries  night  and  day. 
Temperature,  98.6°  F. 

Chief  Complaint. — Vomiting,  crying,  loss  of  weight. 

Previous  Food. —  (1)    Eagle  Brand  condensed  milk,    (2)    top  milk  with  milk 
sugar,   (3)   Eskay's  food  with  whole  milk  and  water,    (4)   skimmed  milk 
with  dextri-maltose. 
Treatment. — Food  prescribed : 

Dry  milk  ....    1  level  tablespoonful    Feed  2  oz.  every  3  hours  at  6,  9, 

Water 2  oz.  12  A.M.,   3,   6,   9   P.M.,   and 

2  A.M. 

December   25:     Weight,  9  Ib.  4  oz. 
No  gain,  no  loss. 
General  Condition. — Unchanged. 
Stools. — One  large,  constipated,  with  enema. 
Vomiting. — Has  not  vomited  once  after  beginning  dry  milk. 
A  ppetite. — Hungry. 
Sleep. — Better,  but  cries  a  good  deal. 
Treatment. — Food  prescribed  r 

Dry  milk 2  tablespoonful s      Feed  3  oz.  every  3  hours  at  6, 

(in  two  days  increase  to  3  table-          9,  12  A.M.,  3,  6,  9  P.M.,  and 

spoonfuls)  2  A.M. 

Water 3  oz. 

December  30:     Weight,  9  Ib.  15  oz. 

Gain,  11  oz. 

General  Condition. — Improved. 
Stools. — One  normal  daily. 
Vomiting. — Vomited  twice  during  the  week. 
A  ppetite. — Hungry. 
Sleep. — Much  better. 


VOMITING  IN  BOTTLE-FED  INFANTS       201 

Treatment. — Food  prescribed: 

Dry  milk    4  tablespoonfuls      Feed  4  oz.  every  3  hours  at  6, 

Water    4  oz.  9,  12  A.M.,  3,  6,  9  P.M.,  and 

2  A.M. 

She  gained  thirteen  ounces  the  following  week  and  continued  to  gain  and 
prosper.  On  July  16th,  when  nine  months  of  age,  she  weighed  twenty-four 
pounds,  having  had  no  other  food  but  the  dry  milk  and  orange  juice  through- 
out these  seven  months.  Her  color  was  good,  the  musculature  was  excellent 
and  there  were  no  evidences  of  rickets  or  other  nutritional  disturbances. 

(3)    OVEKFEEDING  IN    QUANTITY 

It  is  rarely  necessary  to  decrease  the  bulk  of  the  feeding 
or  lengthen  the  intervals  when  boiled  milk  and  water  feed- 
ings are  given  without  sugar,  provided  the  intervals  are  of 
the  proper  length  and  provided  the  bulk  is  not  excessive  for 
the  infant's  size  and  age  (see  p.  62).  Occasionally  the  bulk 
or  the  amount  at  each  feeding  must  be  diminished,  even  if 
this  necessitates  making  the  food  stronger,  in  order  to  get 
in  the  proper  amount  of  nourishment.  A  strong  milk-and- 
water  mixture  will  often  be  better  retained  when  given  in 
small  amounts  than  a  weak  food  that  is  given  in  too  large 
quantities  at  a  feeding.  This  is  particularly  true  of  infants 
who,  through  overfeeding,  have  a  dilated  stomach  or  gastro- 
ptosis.  An  infant  that  is  getting  an  excessive  quantity  at  a 
feeding,  say  eight  ounces  every  two  hours  (not  an  uncommon 
occurrence),  would  have  to  have  this  amount  reduced  to  the 
correct  quantity  for  his  age  and  weight. 

An  infant  that  is  being  fed  too  often,  say  every  hour 
or  whenever  it  cries,  or  at  extremely  irregular  intervals, 
should  have  this  error  corrected. 

Well-nourished  infants  under  six  months  of  age  or  six- 
teen pounds  in  weight  should  be  fed  once  in  three  hours  from 
6  A.M.  to  9  P.M.,  whether  there  is  vomiting  or  not.  Infants  of 
six  months  of  age  wrho  weigh  more  than  sixteen  pounds 
should  be  fed  every  four  hours,  five  feedings  in  twenty-four 
hours.  If  the  infant  is  under  four  or  five  pounds  and  if 
there  is  a  severe  grade  of  emaciation,  diarrhea,  and  other 
gastro-intestinal  symptoms,  it  is  best  to  start  with  two-hour 


; 

202  SIMPLIFIED  INFANT  FEEDING 


intervals  from  6  A.M.  until  10  P.M.,  with  one  feeding  at  2  A.M. 
— ten  feedings  in  twenty-four  hours.  If  the  vomiting  does 
not  stop,  or  if  it  recurs  when  the  sugar  is  added,  two  and 
one-half-hour  intervals  from  6  A.M.  to  9  P.M.  and  one  2  A.M. 
feeding,  making  eight  feedings  in  twenty-four  hours,  should 
be  tried.  If  the  vomiting  still  remains  unabated,  three-hour 
intervals  from  6  A.M.  to  9  P.M.,  with  one  feeding  at  2  A.M., 
making  seven  feedings  in  twenty-four  hours,  may  be  used. 
The  author  has  not  found  it  necessary  to  use  the  four-hour 
intervals  for  any  infant  under  six  months  of  age  or  sixteen 
pounds  in  weight,  although  he  is  cognizant  of  the  fact  that 
many  pediatricians  have  used  these  long  intervals  with 
excellent  results. 

Recently  X-ray  work  has  thrown  a  great  deal  of  light 
upon  the  subject  of  motility  and  the  emptying  time  of  the 
stomach.  The  work  of  numerous  investigators  has  explained 
many  facts  learned  by  clinical  experience  and  seemingly 
contradicted  by  investigators  working  with  the  stomach- 
tube.  Pisek  has  shown  that  when  food  is  given  with  the 
stomach-tube  the  stomach  begins  to  empty  itself  immediately 
— in  fact,  before  the  infant  can  be  brought  to  the  X-ray  plate. 
The  distention  caused  by  the  food  brings  about  an  active 
peristalsis,  so  that  most  of  the  food  leaves  the  stomach 
within  one  and  one-half  to  two  and  one-half  hours.  The 
food  remaining  after  this  length  of  time  may  not  leave  the 
stomach  for  four  and  one-half  to  seven  and  one-half  hours, 
unless  more  food  is  given,  when  the  residue  from  the  former 
feeding  is  immediately  expelled  through  the  pylorus.  This 
fact  would  indicate  one  of  two  things:  either  the  bismuth 
used  in  the  food  for  X-ray  purposes  retards  the  exit  of  this 
last  remaining  portion  of  the  food,  or  the  stomach  of  the 
infant  is  not  intended  to  empty  entirely  before  another 
feeding  is  given.  Ladd  has  shown  that  the  time  it  takes  the 
stomach  to  empty  depends  also  upon  the  food  given  and 
upon  the  individual  infant,  facts  which  are  axioms  of  clini- 
cal observers.  He  has  also  shown  that  the  less  coagulable 


VOMITING  IN  BOTTLE-FED  INFANTS       203 

the  proteid  the  sooner  it  leaves  the  stomach,  and  that  easily 
coagulated  proteids  delay  the  emptying  of  the  stomach 
greatly.  He  has  used  the  curds  (casein)  dried,  which  are 
soluble  in  alkaline  liquids,  and  almost  instantly  cleared  up 
gastric  symptoms  in  some  instances.  Boiling  the  milk  makes 
it  less  coagulable, — that  is,  retards  coagulation  in  the  stom- 
ach,— and  that  is  one  of  the  reasons  the  stomach  empties  so 
much  more  quickly  and  vomiting  stops  when  boiled  milk 
and  water  mixtures  are  used. 

CASE  XLV 

(Illustrating  habitual  vomiting  from  overfeeding  in  quantity,  as  well  as  from 

too  much  sugar. 

May  24:     Age,  8  months.     Weight,  15  Ib.  3  oz. 
General  Condition. — Fairly  well  nourished,  fair  musculature,  no  rickets.    Needs 

50  calories  per  pound  per  day. 
Stoote. — Two  a  day,  brownish  yellow,  occasionally  loose  in  consistency,  with 

mucus;  no  curds. 
Vomiting. — Has  always  vomited  some,  but  in  the  last  six  weeks  the  vomiting 

has  been  more  profuse  throughout  the  interval. 
Appetite. — Fair;  occasionally  leaves  two  or  three  ounces. 
Sleep. — Fairly  good. 
Temperature,  98.6°  F. 
Chief  Complaint. — Vomiting. 
Previous  Food. — Infant  had  been  artificially  fed  since  birth  with  milk,  barley 

gruel,   and  cane  sugar  mixture   in  gradually   increased   quantities.     At 

present: 

Milk  (unboiled)    40  oz.  800  calories      Fed  8  oz.  every  2  hours,  9  or 

Barley  gruel    40  oz.   100  calories  10  feedings     in  24  hours; 

Cane  sugar 2  oz.  240  calories          not  all  taken. 

1140  calories,  or  75+  calories  per  pound. 

Each  feeding  has  been  made  separately  with  four  ounces  of  milk,  four 
ounces  of  barley  gruel,  and  one  lump  of  sugar.  The  total  twenty-four-hour 
amount  should  be  estimated  as  above,  even  when  the  food  has  not  been 
thus  made. 

Treatment. — Food  prescribed: 

Milk    24  oz.  )  480  calories      Divide  into  6  feedings.    Feed 

Water 24  oz.  f  8  ounces  every  3  hours,  al 

Cane   sugar    ....  ^  oz.  60  calories          6,  9,  12  A.M.,  3,  6,  9  P.M. 

540  calories,  or  36-  calories  per  pound. 
May  28    (4  days  later)  :   Weight,    15    Ib.    3   oz. 
No  gain  or  loss. 


204  SIMPLIFIED  INFANT  FEEDING 

General  Condition. — As  at  last  visit. 
Stools. — Two  yellow,  firm ;  no  mucus. 
Vom  iting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk    28  oz.  )  560  calories      Divide  into  6  feedings.    Feed 

Water 20  oz.  f  8  oz.  every  3  hours  as  be- 

Cane  sugar 1  oz.  120  calories          fore. 

680  calories,  or  45-  calories  per  pound. 
May  31    (3  days  later)  :     Weight,   15   Ib.  5  oz. 

Gain,  2  oz. 

General  Condition. — Improved. 
Stools. — Constipated;  one  hard  (voluntary). 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk   28       oz.  |       .         560  calories      Divide   into   6   feedings.      Feed 

Water 20      oz.  f  boiled  8  oz.  every  3  hours  as  before. 

Cane  sugar.      1^  oz.  180  calories 

740  calories,  or  approximately  49  calories  per 
pound. 

This  infant  continued  to  improve,  and  within  the  next  week,  the  caloric 
requirements  being  fulfilled,  gained  nine  ounces.  If  the  appetite  had  been 
good  and  the  infant  had  taken  all  of  the  food  given,  before  it  came  under  treat- 
ment for  the  vomiting,  it  would  have  been  getting  at  least  half  as  much  again 
in  food  value  as  needed,  and  nearly  twice  as  much  in  the  total  twenty-four- 
hour  quantity.  This  was  a  case  of  vomiting  and  lack  of  appetite  due  to  over- 
feeding, too  frequent  feeding,  and  too  much  sugar. 

(4)    THE  HYPEBTONIC  INFANT 

Haas  has  recently  called  attention  to  a  class  of  vomiting 
infants  which  have  a  definite  clinical  entity,  which  he  calls 
the  hypertonic  infant  and  of  which  he  says :  ' '  It  is  charac- 
terized by  hypertonicity  of  all  the  skeletal  muscles,  as  shown 
by  the  ability  to  raise  the  head  and  grasp  objects  even  in  the 
early  days  of  life,  and  by  general  spasticity.  The  hollow 
viscera  show  increased  activity  of  their  smooth  muscle  fibres. 


VOMITING  IN  BOTTLE-FED  INFANTS       205 

This  expresses  itself  in  the  form  of  spasm  involving  prac- 
tically every  part  of  the  digestive  tube,  and,  depending  on 
the  region,  presents  the  symptoms  of  colic,  visible  peristalsis, 
vomiting,  constipation  or  any  combination  of  these.  Accom- 
panying these  symptoms  is  a  marked  psychic  irritability, 
expressed  by  insomnia,  general  restlessness  and  crying.  The 
hypertonic  infant  belongs  to  the  SpasmophiUc  group. 

"Cases  of  this  type  present,  in  order  of  their  importance : 

* '  1.  Vomiting,  which,  as  before  mentioned,  is  characteris- 
tically irregular,  often  with  visible  peristalsis. 

' '  2.  Crying,  which  is  often  more  or  less  violent. 

"3.  Insomnia;  this  is  usually  a  striking  symptom,  and 
with  the  crying  creates  a  household  state  or  condition 
bordering  on  demoralization. 

"4.  Constipation,  resistant  to  ordinary  laxative  and  die- 
tetic treatment,  and  distinctly  spastic  in  type,  the  stool  being 
soft  after  it  is  once  started. 

"5.  Cold  extremities,  with  pallor,  cyanosis  and  subnor- 
mal temperature.  This  is  met  with  only  occasionally. 

"6.  Underweight,  the  degree  depending  on  the  age  at 
which  correct  treatment  is  instituted — under  eight  weeks,  one 
to  one  and  a  half  pounds ;  from  three  to  six  months,  three  to 
four  pounds."  (Haas,  from  the  American  Journal  of  Dis- 
eases of  Children,  May,  1918.) 

This  type  of  infant  is  so  common  that  it  is  remarkable 
that  no  one  else  has  ever  before  so  classified  them,  but 
equally  important  is  the  discovery  of  the  correct  treatment. 
These  infants  vomit  profusely  and  frequently;  they  cry 
night  and  day.  Even  the  most  skilful  infant  feeders  have 
difficulty  in  controlling  the  vomiting  and  other  symptoms 
dietetically,  but  Haas  in  his  original  communication  an- 
nounced that  "treatment  by  the  drug  atropin  is  followed 
by  rapid  subsidence  of  symptoms,  the  results  being  so  prompt 
and  regular  as  to  constitute  specific  action."  The  author 
is  just  as  enthusiastic  about  the  uses  of  atropin  as  the  origi- 


206  SIMPLIFIED  INFANT  FEEDING 

nator.  Repeatedly  he  has  seen  the  vomiting  cease  after  the 
first  dose  of  atropin,  and,  within  a  few  hours,  the  infant  stop 
crying  and  change  immediately  from  a  fretful,  irritable 
infant  into  a  normal  one.  This  is  not  to  be  interpreted  as 
meaning  that  the  improperly  fed  infant  will  stop  vomiting 
when  given  atropin,  for  that  is  not  the  type  of  infant  who 
is  meant  to  receive  this  treatment.  It  is  the  infant  whose 
feedings  have  been  properly  managed  and  who,  in  spite  of 
the  most  careful  attention,  still  vomits  and  cries  as  much  as 
ever.  The  atropin  is  administered  in  the  following  manner : 

B 

Atropin    gr.  i 

Water   3ii 

(1  :  1000  solution) 
Sig. — One  drop  in  each  feeding.    Put  into  the  bottle. 

One  grain  to  the  ounce  of  water  makes  a  solution  of  which 
each  drop  contains  grains  1/480.  This,  then,  is  the  dose 
to  start  with.  If  within  forty-eight  hours  the  symptoms 
are  not  very  much  improved,  or  if  the  vomiting  recurs  at 
any  time,  the  dose  would  be  increased  to  two  drops  in  each 
feeding.  In  almost  every  case  two  drops  will  act  so  promptly 
that  it  is  not  necessary  to  increase  it  further,  but  if  it  does 
not,  it  is  safe  to  increase  the  dose  to  even  three  or  four  drops 
(at  intervals  of  two  or  three  days).  The  hypertonic  infant 
is  not  sensitive  to  atropin,  but  one  should  be  on  the  lookout 
for  its  toxic  manifestations,  which  are  flushing,  restlessness, 
vomiting,  diarrhoGa,  hyperpyrexia  and  abdominal  distention. 
Atropin  is  so  much  of  a  specific  that  if  it  fails  to  stop  the 
vomiting  it  is  of  diagnostic  value ;  that  is,  a  mistake  in  the 
diagnosis  has  been  made.  It  is  not  of  value  in  acute  vomit- 
ing nor  in  habitual  vomiting  due  to  incorrect  feeding. 

CASE  XLVI 

(Illustrating  the  use  of  atropin  in  vomiting  of  the  hypertonic  infant) 
March    25:     Age,    5    weeks.     Weight,  8  Ib.   11  oz. 

Birth  weight,  8  Ib.  12  oz. 


VOMITING  IN  BOTTLE-FED  INFANTS       207 

General  Condition. — Muscular  type,  cold  feet,  poorly  nourished. 

Stools. — Constipated  stool  with  suppository  each  day. 

Vomiting. — Almost  every  feeding,  seemingly  all  that  was  taken,  occasionally 
projectile. 

Appetite. — Hungry. 

Sleep. — Cries  night  and  day. 

Temperature,  98.6°  F. 

Chief  Complaint. — Vomiting,  colic. 

Previous  Food: 

Milk    9  oz.  Fed  3  oz.  every  2-3  hours ;  8  bot- 

Water   15  oz.  ties  in  24  hours. 

Dextri-maltose    6  tablespoonfuls 

Treatment. —  (1  :  1000  atropin  solution,  1  drop  in  each  bottle.)  Food  pre- 
scribed : 

Dry  milk 1,  increased  to  2  tbs.      Feed  3  oz.  every  3  hours,  at  6  y  9,  12 

Water 3  oz.  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

April   1:     Weight,  8   Ib.   15  oz. 
Gain,  4  oz. 

General  Condition. — Same. 

Stools. — One  firm  with  suppository. 

Vomiting. — A  little  after  each  feeding. 

Appetite. — Hungry. 

Sleep. — Better,  but  still  cried  a  good  deal. 

Treatment. — Increase  atropin  solution  to  two  drops  in  each  feeding. 

Dry  milk  3  tablespoonfuls      Feed  3  oz.  every  3  hours,  at  6, 

Water    3  oz.  9,  12  A.M.,  3,  6,  9  P.M.,  and 

2  A.M. 
April   8:     Weight,   10  Ib.  4  oz. 

Gain,  1  Ib.  5  oz.  in  7  days. 
General  Condition. — Much  improved. 
Stools. — Three  to  four  firm,  normal. 
Vomiting. — None. 
.4.  ppet  i  te. — Hungry. 
Sleep. — Excellent. 
Treatment. — Atropin  2  drops  in  each  bottle. 

Food  Prescribed: 

Dry  milk 3  tablespoonfuls      Feed  3%  oz.  every  3  hours  at  6, 

Water  3%  oz.  9,  12  A.M.,  3,  6,  9  P.M.,  and  2 

A.M. 

April   15:     Weight,   10  Ib.   13  oz. 
Gain,  9  oz.  in  7  days. 
General  Condition. — Excellent. 
Stools. — Three  large,  firm,  normal. 


208 

Vomiting. — None. 

Appetite. — Good. 

Sleep. — Good. 

Treatmen  t. — Food  prescribed : 

Dry  milk  3%  tablespoonfuls      Feed  4  oz.  every  3  hours  at  6, 

Water   4  oz.  9,  12  A.M.,  3,  6,  9  P.M.,  and  2 

A.M. 

On  June  third,  six  weeks  later,  the  baby  weighed  fourteen 
pounds  four  ounces.  There  had  been  no  recurrence  of  the 
vomiting  and  colic  and  the  atropin  was  discontinued. 

(5)    OKGANIC  CAUSES  OF  VOMITING 

Reflex  vomiting  will  not  be  discussed  here.  Pyloric  ste- 
nosis and  spasm  of  the  pyloris  are  two  diseases  with  which 
physicians  should  be  familiar  but  which  will  only  be  briefly 
discussed  as  they  more  properly  belong  to  a  textbook  on 
pediatrics.  Symptoms  which  are  common  to  both  are  pro- 
jectile vomiting,  constipation,  emaciation,  loss  of  weight 
or  failure  to  gain  in  weight.  Visible  peristalsis  is  commonly 
seen  in  the  spasm  of  the  pylorus  but  is  more  marked  in  a 
true  organic  stenosis  (obstruction).  In  organic  stenosis  a 
mass  may  be  felt  in  the  right  epigastrium  by  the  skilled 
palpator.  It  is  never  felt  in  spasm  of  the  pylorus.  These 
two  conditions  may  be  differentiated  by  X-ray,  by  the  extent 
and  constancy  of  the  vomiting,  and  by  the  amount  of  food 
which  gets  through  the  pylorus,  as  determined  by  the  size 
and  quantity  of  the  stools  and  the  degree  of  emaciation.  The 
administration  of  atropin  is  of  additional  aid  in  the  differ- 
ential diagnosis,  since  it  will  control  the  vomiting  of  pyloric 
spasm,  while  it  will  have  no  effect  on  organic  stenosis.  In 
cases  where  pyloric  spasm  is  suspected  atropin  treatment 
should  be  started  at  once  and  is  just  the  same  as  for  the 
hypertonic  infant  (see  page  206).  On  the  other  hand,  true 
organic  obstruction  should  be  operated  upon  at  once,  since 
the  mortality  for  the  Rahmstead  operation  is  very  low  indeed 
when  done  early. 


CHAPTER  XVI 

LOSS  OF  APPETITE  IN  BOTTLE-FED  INFANTS 

Loss  of  appetite  in  bottle-fed  infants  is  evidenced  by  the 
infant's  failure  to  take  all  the  food  offered  at  any  or  all 
the  feedings,  and  it  may  at  times  be  a  very  serious  condition. 
It  is  very  important  for  an  infant  to  take  all  the  food  that  is 
planned  for  it,  since  it  is  useless  carefully  to  reckon  the 
needs  of  an  individual  infant  when  it  is  getting  only  a  por- 
tion of  the  food  it  requires.  Unfortunately  an  infant 's  appe- 
tite is  not  always  a  proper  guide  to  its  needs.  It  is  difficult 
to  get  some  infants  to  take  food  that  is  sufficient  in  strength 
and  quantity,  while  others  will,  if  permitted,  take  ravenously 
enough  food  to  give  them  gastric  or  intestinal  indigestion. 
This  excessive  appetite  is  often  more  marked  when  indiges- 
tion is  already  present. 

A  lack  of  appetite  is  noticeable  in  four  classes  of  infants : 

(1)  Those  who  are  wrongly  fed  or  overfed  or  irregu- 
larly fed. 

(2)  Those  properly  fed,  who  have  a  very  narrow  margin 
between  their  digestive  capacity  and  the  amount  of  food 
that  they  need  to  make  a  gain  in  weight. 

(3)  Small,  emaciated  infants  who  are  too  weak  to  take 
the  food.    These  infants  are  usually  also  wrongly  fed. 

(4)  Infants  with  sore  mouth  or  throat  or  some  other 
pathological  condition  which  makes  it  painful  or  difficult  for 
the  infant  to  swallow. 

(1)  Infants  Who  are  Wrongly  Fed  or  Overfed. — It  is  not 
at  all  difficult  to  overcome  loss  of  appetite  in  infants  who 
are  wrongly  fed  or  overfed.  Fortunately  again,  the  same 
treatment  which  helps  most  of  the  cases  of  diarrhea  and 
vomiting  is  beneficial  in  increasing  the  appetite,  so  that  the 

14  209 


210  SIMPLIFIED  INFANT  FEEDING 

usual  mixture  of  one-third  milk  and  two-thirds  water  (or 
half  milk  and  half  water  for  the  larger  infants  who  have 
been  accustomed  to  strong  milk  mixtures)  will  cause  the 
appetite  of  these  infants  to  increase  in  a  very  few  days, 
sometimes  inside  of  twenty-four  hours.  The  sugar  should 
be  reduced  or  taken  from  the  food  altogether,  and,  if  top 
milks  are  used,  it  is  best  to  substitute  whole-milk  mixtures 
for  them. 

Unless  the  infant  is  feeble  and  greatly  undersized,  the 
intervals  between  feedings  should  be  increased  to  three 
hours,  giving  either  six  or  seven  feedings  in  twenty-four 
hours,  the  food  being  given  in  the  proper  quantity  for  the 
age  (see  p.  62).  It  is  never  best  to  cut  down  the  quantity 
at  a  feeding  simply  because  the  infant  does  not  take  all  that 
is  given,  unless  the» quantity  has  been  excessive.  If  the  sugar 
is  stopped  and  the  dilution  given  as  suggested  above,  the  in- 
fant will  take  the  proper  quantity.  The  sugar  should  not 
be  added  nor  the  food  increased  to  a  sufficient  strength 
to  supply  the  infant's  needs  (caloric  requirements)  until  the 
proper  quantity  is  taken  at  each  feeding.  Then- the  increase 
should  be  made  in  the  usual  gradual  manner. 

CASE  XLVII 
(Illustrating  loss  of  appetite  and  its  control  by  reducing  the  amount  of  milk 

and  sugar  and  lengthening  the  intervals  between  feedings) 

March  23:     Age,   7  months  3   weeks.     Birth   weight,   6%    Ib. 

Present  weight,  15  Ib. 
General  Condition. — Fairly  well  nourished,  somewhat  pale,  good  musculature. 

Caloric  needs,  50  calories  per  pound  per  day. 
Stools. — Two  a  day  with  enema;  castor  oil  occasionally. 
Vomiting. — Every  day  a  little. 

Appetite. — For  last  six  days  poor;  leaves  four  ounces  every  feeding. 
Sleep. — Restless  at  night.     Sleeps  two  hours  in  the  morning  and  one  hour 

in  the  afternoon. 
Temperature,  98.6°  F. 
Chief  Complaint. — Loss  of  appetite. 
Previous  Food. — Infant  had  been  breast-fed  for  six  weeks;    since  then  had 

milk,  water,  and  sugar  mixtures  of  various  strengths.    For  four  weeks: 


FEEDING  TABLE  No.  1 

FEEDING  MIXTURES  SUITABLE  FOR  THE  AVERAGE  WELL  BABY 


Baby's 
Age 
in 

Months 

Weight 
of 
Baby 
Pounds 

Amount 
Cow's 
Milk 
Ounces 

Amount 
Boiled 
Water 
Ounces 

Rounded 
tablespoon- 
fuls  Dextri- 
Maltose 

Amount 
of  each 
Feeding 
Ounces 

Number 
Feedings 
in 
24  Hours 

1-2 

7 
8 
9 
10 
11 

9 

12  
14 
16 
18 

12 
-  16 
14 
16 
14 

3 

3 
3 
3 
3 

3 

4 

4>2 

«H 

7 

! 

7 

3-4            f 

10 
11 

^8 

14 

16 
18 
20 
22 
24 

14 
12 
16 
14 
12 

3 

3 
3 
3 
3 

5 

5 
6 
6 
6 

6 

6 
6 
6 
6 

5-6 

13 

14 
15 
16 

22 

24 
26 

28 

13 
11 
9 
12 

3 
3 
3 
3 

7 

7 
7 
8 

5 
5 
5 
5 

7-8-9 

14 
15 
16 
17 
18 
19 

24 
26 
28 
30 
32 
34 

16 
14 
12 

10 
8 
6 

3 
3 
3 
3 
3 
3 

8 

8 
8 
8 
8 
8 

5 

5 
5 
5 
5 
5 

10-11-12 

20 
21 
22 
23 
24 

36 

38 
40 
40 
40 

4 
2 
0 
0 
0 

3 
3 
2 
2 
3 

8 
8 
8 
8 
8 

5 

5 
5 
5 
5 

NOTE:  For  first  few  days  use  2  tablespponfuls  Dextri-Maltose.  Ag  soon  as  this 
is  well  bourne  increase  gradually  to  3.  Always  give  baby  plenty  of  water  between  feedings. 
In  ordinary  feeding  cases  use  Dextri-Maltose  No.  1.  If  infant  suffers  from  constipation 
use  Dextri-Maltose  No.  3. 

HOURS  TO  FEED 

10  Times  per  day— 6,  8,  10,  12  A.  M.;  2,  4,  6,  8,  10,  P.  M.;  2  A.  M. 
8  Times  per  day— 6,  8:30,  11  A.  M.;  1:30,  4,  6:30,  9  P.  M.;  2  A.  M. 
7  Times  per  day— 6,  9,  12  A.  M. ;  3,  6,  9  P.  M. ;  2  A.  M. 
6  Times  per  day— 6,  9,  12  A.  M.;  3,  6,  9  P.  M. 
6  Times  per  day— 6,  10  A.  M.;  2,  6,  10  P.  M. 


211 

hours, 
urs. 


Feed 
urs,  at 
P.M. 


tunces. 


INTESTINAL-INDIGESTION-DIARRHOEAS. 

When  baby  is  having  Loose,  Green  or  Yellowish  Stools,  containing  mucus  «r  curds 
immediately  omit  Dextri-Maltose  and  boil  the  milk  and  water  mixture  2  minutes.  Then 
cool  to  blood  heat  and  feed.  As  stools  become  normal,  gradually  add  the  Dextri-Maltose 
to  the  feedings  until  the  prescribed  quantity  for  well  babies  is  reached. 

In  the  condition  above  described,  but  where  the  baby  is  having  temperature  (in- 
fectious diarrhoeas)  give  a  cathartic  and  starvation  diet  for  12  hours,  (weak  tea  or  barley 
water)  after  12  hours  begin  with  the  milk  and  water  feeding,  boiling  same  as  above,  omitting 
the  Dextri-Maltose  until  the  stools  become  normal,  then  gradually  add  the  Dextri-Maltose 
until  the  baby  is  taking  the  prescribed  quantity  for  its  age  and  weight. 

REGURGITATION-VOMITING 

When  baby  vomits  or  spits  up  shortly  after  feeding,  boil  the  milk  and  water  together 
for  2  minutes  and  reduce  the  amount  of  each  feeding  for  a  few  days,  returning  to  the 
regular  feeding  as  soon  as  vomiting  stops. 

Regurgitation  is  often  prevented  by  placing  the  baby  in  an  upright  position  immed- 
iately after  he  has  finished  nursing,  with  his  head  on  the  mother's  shoulder,  patting  him 
gently  on  the  buttocks  until  he  has  expelled  the  air  swallowed  during  nursing. 

REGULATING  THE  DIET  IN  CONSTIPATION 

Many  cases  of  constipation  in  the  bottle-fed  baby  are  the  result  of  a'negative  balance 
of  the  potassium  and  calcium  salts.  In  such  cases  the  use  of  Dextri-Maltose  No.  3  in  the 
same  amount  as  Dextri-Maltose  No.  1,  or  any  other  form  of  sugar  will  change  this  balance 
and  will  generally  produce  soft,  normal  stools.  In  some  instances,  especially  in  older 
infanta,  it  is  necessary  to  increase  temporarily  the  amount  of  Dextri-Maltose  No.  3  to  4 
tableepoonfuls  in  order  to  obtain  the  desired  results,  after  which  continue  with  three 
rounded  tablespoonfuls  of  Dextri-Maltose  No.  3. 


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LOSS  OF  APPETITE  211 

Milk  29       oz.  )           .            Fed  7  ounces  every  2  y2  hours, 

Water    24      oz.  f  "^                 8  feedings  in  24  hours. 

Cane   sugar    1  ^  oz. 

Peptogenic  milk  powder . .     2      oz. 

Treat/new*. — Food  prescribed: 

Milk    28  oz.  )  560  cals.      Divide  into  6  feedings.    Feed 

Water 20  oz.  j  ^^  8  ounces  every  3  hours,  at 

Cane  sugar y2  oz.  60  cals.          6,  9,  12  A.M.,  3,  6,  9  P.M. 


620  cals.  41  calories  per  pound. 
March  27  (4  days  later)  :    Weight,  15  Ib. 

No  gain  or   loss. 

General  Condition. — As  at  last  visit. 
Stools. — Two  normal  with  enema  or  castor  oil. 
Vomiting. — None. 

Appetite. — Hungry:  takes  all  the  food  ravenously. 
Sleep. — Restless. 
Temperature. — Same. 
Treatment. — Food  given: 

Milk   28      oz.  )  .         560  cals.      Divide  into  6  feedings.    Feed 

Water    20       oz.  f  "^iled  8  ounces  every  3  hours  as 

Cane  sugar  ....1-1%  oz.  180  cals.          before. 

740  cals.  50  calories  per  pound. 
In  three  days,  if  still  hungry,  increase  sugar  to  one  and  a  half  ounces. 

April  4  (8  days  later  ^  :     Weight,  15  Ib.  9  oz. 

Gain,  9  oz. 

General  Condition. — As  at  last  visit. 
Stools. — One  normal. 
Vomiting. — Xone. 

Appetite. — Good;  all  the  food  taken. 
Sleep. — Good. 

This  infant  continued  to  do  well,  and  at  eleven  months 
of  age  was  of  normal  weight.  It  had  been  getting  a  great 
deal  too  much  food  as  well  as  an  excess  of  sugar,  since 
the  peptogenic  milk  powder  is  made  largely  of  milk  sugar 
and  pancreatin,  and  two  ounces  of  this  plus  one  and  a  half 
ounces  of  cane  sugar  made  three  and  a  half  ounces  of 
sugar  in  all.  The  mother  objected  at  first  to  the  change  in 
feeding  made  at  the  first  visit,  because  she  considered  the 
peptonizing  essential  to  prevent  indigestion.  It  will  be  seen 


212  SIMPLIFIED  INFANT  FEEDING 

how  the  digestion  was  improved  after  the  peptogenic  milk 
powder  was  stopped. 

CASE  XL VIII 

(Illustrating  loss  of  appetite  from  overfeeding) 
June  19:     Age,  6  months.     Birth  weight,  4  Ib.  (?)    (premature). 

Present  weight,  7  Ib.  4  oz. 
General  Condition. — Emaciated,  pale,  poor  musculature,  no  evidences  of  rickets, 

feeble  cry.     Caloric  needs  65  per  pound  per  day. 
Stools. — For  three  months,  constipated;  one  light  yellow,  hard  stool  with  an 

enema  each  day. 
Vomiting. — None. 

Appetite. — Takes  less  than  half  the  feeding. 
Sleep. — Poor;  cries  night  and  day. 
Temperature,  98°  F. 

Chief  Complaint. — Loss  of  appetite,  emaciation. 
Previous  Food  and  Feeding  History. — First  month  of  life  fed  Eagle  brand 

condensed  milk,  second  and  third  months  Horlick's  malted  milk,  fourth 

and  fifth  months  malted  milk  with  gradually  increased  amounts  of  cow's 

milk.     For  two  weeks: 

Milk   28  oz.  )  560  calories      8  oz.  every  3  hours,  7  feed- 
Water  28  oz.  \  unbo  ings  in  24  hours. 

Malt  sugar   ...     2  oz.  240  calories 

800  calories,  or  1 10+  calories  per  pound. 
Treatment. — Food  prescribed : 

Milk 18  oz.  |  360  calories      Divide  into  7  bottles.  Feed 

Water   18  oz.  \  u  5  oz.  every  3  hours  at  6, 

Sugar 0  9,  12  A.M.,  3,  6,  9  P.M.,  and 

2  A.M. 

or  50-  per  pound. 

June  23   (4  days  later) :     Weight,  7  Ib.  4  oz. 
General  Condition. — Somewhat  improved. 
Stools. — One  a  day  with  enema. 
Vomiting. — None. 
Appetite. — Takes  all  food  eagerly. 
Sleep. — Better. 

Treatment. — Food  prescribed: 

Milk    18  oz.  I  360  calories        Divide  into  7  feedings.    Feed 

Water     18  oz.  \  v  5  oz.  every  3  hours  as  be- 

Malt  sugar    . .   %  oz.  60  calories           fore. 

420  calories,  or  55-  per  pound. 

This  baby  continued  to  take  the  food  well,  and  the  sugar  was  gradually 
increased  to  one  ounce  in  the  twenty-four-hour  amount. 


LOSS  OF  APPETITE  213 

(2)  Babies  properly  fed,  who  have  a  very  narrow  margin 
between  their  digestive  capacity  and  the  amount  of  food  that 
they  need  to  make  a  gain  in  weight,  are  more  difficult  to  treat. 
Occasionally  one  sees  an  infant  who  gains  but  slowly 
when  given  the  proper  amount  of  milk,  water,  and  sugar, 
and  whose  appetite  is  not  good.  If  an  infant  cannot  be 
made  to  take  the  amount  of  food  it  needs,  it  will  not  gain 
in  weight.  For  such  an  infant  the  food  requirements  must 
be  carefully  reckoned.  Because  of  this  very  narrow  margin, 
a  few  ounces  of  milk  more  than  is  needed  will  spoil  the 
appetite,  even  though  there  is  no  diarrhoea  or  vomiting. 

The  best  that  can  be  done  in  such  cases  is  to  cut  down 
the  food,  particularly  the  sugar,  to  the  quantity  that  the 
infant  will  take  well,  and  not  expect  a  gain  in  weight  until 
after  the  appetite  has  returned.  The  intervals  may  be 
lengthened  to  three  hours  or,  in  infants  over  eight  months  of 
age,  even  to  four  hours.  When  the  appetite  has  returned  so 
that  all  of  the  food  is  eagerly  taken,  the  sugar  and  milk  may 
be  gradually  increased,  being  careful  not  to  exceed  the 
amount  that  will  cause  a  return  of  the  loss  of  appetite. 
Such  children  may  not  be  expected  to  gain  weight  very 
fast,  a  gain  of  three  or  four  ounces  a  week,  while  the  tendency 
to  lack  of  appetite  persists,  being  all  that  may  be  expected. 

Occasionally  strychnia,  gr.  tfa  to  -5^5-  given  every  six 
hours  before  a  feeding,  will  improve  the  appetite. 

CASE  XLIX 
( Illustrating  a  case  in  which  loss  of  appetite  repeatedly  recurred  whenever  the 

food  was  increased  beyond  the  infant's  minimum  caloric  requirements ) 
March  2:     Age,  4  months  2  weeks.     Birth  weight,  5  Ib.  10  oz. 

Present  weight,  9  Ib.  2  oz. 
(Lowest  weight  at  1  month  of  age,  4  Ib. 

8  oz.) 
General  Condition. — Undersized,  fairly  well  nourished,  pale,  rickets.     Caloric 

needs  for  an  8  oz.  weekly  gain,  55  calories  per  pound  per  day. 
Stools. — One  or  two  yellow,  normal  stools  a  day  following  varying  amounts  of 
milk  of  magnesia. 


214 


SIMPLIFIED  INFANT  FEEDING 


Vomiting. — None. 

Appetite. — Leaves  an  ounce  or  two  at  each  feeding. 

Sleep. — Good,  night  and  day. 

Temperature,  98.6°  F. 

Chief  Complaint. — Poor  appetite. 

'Previous  Food : 

Skimmed  milk . .        .16  oz. 


>  unboiled 
20  per  cent,  cream.  . .     4  oz.J 

Water 20  oz. 

Imperial  granum...      5  tbsp. 
(Milk  not  boiled  with  im- 
perial granum) 

Treatment. — Food  prescribed : 

Milk..      .    16  oz. )  ,     320  calories 

f  unboiled 


Fed  4  oz.  every  3  hours,  7  feedings 
in  24  hours. 


Water  ...   16  oz.  / 

Sugar 0 

March  6    (4  days  later): 


Divide  into  7  bottles.     Feed  4y2 
oz.  every  3  hours  at  6,  9,   12 
A.M.,  3,  6,  9  P.M.,  and  2  A.M. 
Weight,  9  Ib.  2  oz. 
No  gain  or  loss. 
General  Condition. — As  above. 
Stools. — Constipated;  one  hard  with  enema. 
Vomiting. — None. 

Appetite. — Good;  takes  all  the  food. 
Sleep. — Good. 

Treatment . — Food  prescribed : 

Milk 18  oz.)  360  calories      Divide  into  7  bottles.     Feed 

Water 18  oz.J  5+  oz.  every  3  hours  at  6, 

Dextri-maltose. . .   %  °z-  60  calories  9,  12  A.M.,  3,  6,  9  P.M.,  and 

2  A.M. 


420  calories,  or  47-  calories  per  pound. 
March  10  (4  days  later)  :     Weight,  9  Ib.  4  oz. 

Gain,  2  oz. 

General  Condition. — Improved. 
Stools. — One  normal. 
Vomiting. — None. 
Appetite. — Takes  all  the  food. 
Sleep. — Good. 

Treatment. — Food  prescribed: 

Milk 18  oz.  )  ,    360  calories 

„-  .  >  unboiled 

Water 18  oz.  J 

Dextri-maltose..     1  oz.  120  calories 


Divide   into    7    bottles 
feed  as  before. 


and 


480  calories,  cr  52-  calories  per  pound. 


LOSS  OF  APPETITE 


215 


March  16   (6  days  later)  :     Weight,  9  Ib.  6  oz. 

Gain,  2  oz. 

General  Condition. — As  at  last  visit. 
Stools. — One  normal. 
Vomiting. — None. 

Appetite. — Leaves  one  to  three  ounces  at  a  feeding. 
Sleep. — Good. 
Treatment. — Food  prescribed: 

Milk 18  oz.)  .   360  calories      Feed  5-f  oz.  every  3  hours 

Unboiled 


Water 18  oz.j 

Dextri-maltose. . .   %  oz. 


60  calories 


7  feedings  in  24  hours  as 
before. 


420  calories,  or  45-  calories  per  pound. 

The  sugar  had  to  be  cut  down  again  and  the  number  of  calories  diminished 
on  account  of  the  loss  of  appetite  at  this  date. 

March  20  (4  days  later)  :     WTeight,  9  Ib.  7  oz. 

Gain  1  ounce  only,  on  account  of  the  low  caloric  value  of  the  food. 
General  Condition. — As  at  last  visit. 
Stools. — One  or  two  normal. 
Vomiting. — None. 

Appetite. — Good;  takes  all  the  food. 
Sleep. — Good. 
Treat m  en  t. — Food  prescribed : 


Milk 


18  oz.1 


"  }•  unboiled 
Water 18  oz.j 

Dextri-maltose. . .   %  oz. 


360  calories       Divide  into  7  bottles.    Feed 
5+  oz.  every  3  hours  as 
90  calories          before. 


450  calories,  or  47+  calories  per  pound. 
The  appetite  now  being  good,  a  small  increase  in  sugar  may  be  made. 


Weight,  9  Ib.  12  oz. 
Gain,  5  oz. 


March  27  (7  days  later) 

General  Condition. — As  at  the  last  visit. 

Stools. — One  or  two  normal. 

Vomiting. — None. 

Appetite. — Fair;  leaves  no  food. 

Sleep. — Good. 

Treatment. — Food  unchanged. 

April  3  (7  days  later)  :     Weight,  10  Ib. 

Gain,  4  oz. 

Ger^eral  Condition. — As  at  last  visit. 
Stools. — One  normal. 
Vomiting. — None. 

Appetite. — Never  really  hungry  enough  to  finish  all  the  food. 
Sleep- — Good. 


216  SIMPLIFIED  INFANT  FEEDING 

This  infant  continued  to  gain  at  a  slow  rate.  Whenever  the  food  was 
increased  too  fast,  the  lack  of  appetite  would  return.  Fortunately  this  illus- 
trates a  very  small  class  of  casee,  for  such  infants  are  very  unsatisfactory 
to  feed  and  the  progress  is  always  slow.  The  author  has  found  the  appetite 
to  remain  poor  throughout  the  second  or  even  third  year  in  some  instances. 

(3)  Smaller,  emaciated  infants  who  are  too  weak  to  take 
the  food  are  usually  also  wrongly  fed.  Inanition  and  sheer 
lack  of  strength  is  the  greater  part  of  the  cause  of  poor 
appetite  in  these  infants,  although  originally  it  may  have 
been  due  to  wrong  feeding.  Some  of  these  infants  will 
linger  over  a  bottle  for  an  hour,  in  spite  of  the  efforts  of 
mother  or  nurse  to  make  them  take  the  food.  It  will  readily 
be  seen  that  an  infant  who  is  nursed  every  two  hours  and 
takes  an  hour  at  the  bottle  will  actually  be  nursing  eight  or 
ten  hours  out  of  the  twenty-four.  This  is  extremely  fatigu- 
ing and  harmful.  In  such  cases  it  is  necessary  to  use  a 
nipple  with  a  very  large  hole,  so  that  the  milk  will  flow  freely. 
If  it  is  not  well  taken  in  this  way,  it  must  be  fed  with  a  medi- 
cine dropper,  so  that  it  may  get  the  food  with  the  least  effort. 

As  for  the  food  itself,  stop  the  sugar  altogether  for  a 
short  period  and  give  the  milk  and  water  boiled,  usually 
one-quarter  milk  and  three-quarters  water  in  this  particular 
class  of  cases.  One  should  guard  against  giving  this  dilute 
food  without  sugar  too  long  lest  the  infant  lose  rapidly  in 
weight.  Twenty-four  hours  is  as  long  as  a  very  weak, 
emaciated  infant  can  stand  weak  food  without  sugar.  These 
small,  poorly-nourished  infants  should  be  fed  at  two-hour 
intervals. 

.Strychnia  is  particularly  effective  when  given  to  this 
class  of  infants,  for  it  not  only  stimulates  the  appetite,  but  its 
general  action  as  a  tonic  is  very  much  needed.  It  has  helped 
to  tide  many  an  infant  over  a  serious  crisis. 

Feeding  by  gavage  (see  p.  341)  is  occasionally  resorted  to. 
An  infant  who  cannot  be  made  to  eat  by  any  of  the  above 


FIG.  11. — The  stomach  tube  for  gavage. 


LOSS  OF  APPETITE  217 

methods  must  be  fed  with  the  stomach-tube,  though  such 
feedings  should  not  be  continued  longer  than  are  absolutely 
necessary.  Give  the  feedings  in  this  way  for  one  day  and 
then  try  the  bottle.  If  the  infant  will  not  siick  the  nipple 
then,  feed  with  the  tube  for  another  day  and  again  try  the 
bottle.  If  it  is  not  taken,  the  tube  feeding  may  be  continued, 
but  the  bottle  should  be  offered  several  times  a  day. 

CASE  L 

(Illustrating  lack  of  appetite  and  its  treatment  in  feeble  and  emaciated  infante) 
June  1 :     Age,  2  months  2  weeks.     Birth  weight,  8  Ib. 

Present  weight,  5  Ib.  9  oz. 
General  Condition. — Extremely  emaciated,  feeble ;  had  atelectasis  at  birth,  some 

signs  of  which  remain.    Caloric  needs,  65  calories  per  pound  per  day. 
Stools. — One  to  three  normal. 
V  o  mit  ing. — Non  e. 
Appetite. — Leaves  half  the  food. 
Sleep. — Twenty-three  out  of  twenty-four  hours. 
Temperature,  97.6°  F. 
Chief  Complaint. — Poor  appetite. 
Previous  Food. — Nestle's  food  and  water  mixture,  fed  two  ounces  every  two 

hours,  ten  feedings  in  24  hours. 

Treatment. — Strychnia,  gr.  V300   every  six  hours  before  a  feeding. 
Food  prescribed: 

Milk 10  oz.-> ...   ,     200  calories       Divide  into  10  bottles.     Feed  3 

Water 20  oz.  j  oz.  every  2  hours,  at  6,  8,  10, 

Sugar 0  12  A.M.,  2,  4,  6,  8,  10  P.M., 

and  2  A.M. 

36  -f-  calories  per  pound. 
June  3(2  days  later)  :     Weight,  5  Ib.  8  oz. 

Loss,  1  oz. 

General  Condition. — As  at  last  visit. 
Stools. — One  normal. 
Vomiting. — None. 

Appetite. — Good;  takes  all  the  food. 
Sleep. — Excellent. 
Treatment. — Food  prescribed : 

Milk 10  oz.  J  200  calories       Divide  into  10  feedings. 

Water 20  oz.  j"  Feed    3    oz.    every    2 

Dextri-maltose.  ys  oz.  (Ms  level  tbsp.)    15  calories           hours  as  before. 

215  calories,  37+  calories  per  pound. 


218 


SIMPLIFIED  INFANT  FEEDING 


June  6  (3  days  later)  :     Weight,  5  Ib.  9  oz. 
General  Condition.—  The  same.  Gain>  *  oz- 

Stools.  —  Two  or  three  normal. 
Vomiting.  —  None. 

Appetite.  —  Good;  fakes  all  the  food. 
Sleep.  —  Cries  two  or  three  hours  a  day.     (Was  too  weak  to  cry  much  before, 

and  now  the   cry  is  of  good  import,   as  it   indicates  that  the   infant  is 

hungry.) 
Treatment.  —  Food  prescribed: 


Milk..  .   10  oz 

Water  ........   20  oz 

Dextri-maltose  .    %  oz. 


.). 

/•  no  i 
.  j 


. 

no  i  1  PH. 


200  calories 


30  calories 


Feed   3   oz.   every   2   hours,    10 
feedings  in  24  hours  as  before. 


230  calories,  36+  per  pound. 

Increase  the  milk  one  ounce  a  day,  decreasing  the  water  the  same  amount 
until  fifteen  ounces  of  milk  and  fifteen  ounces  of  water  are  given. 
June  11    (5  days  later)  :     Weight,  5  Ib.  15  oz. 


General  Condition.—  The  same. 

Stools.  —  Three  normal. 

Vomiting.  —  None. 

Appetite.  —  Good. 

Sleep.  —  Good. 

Treatment.  —  Food  prescribed: 

Milk  ..........    15  oz. 

Water  .........   15  oz. 

Dextri-maltose.    14  oz. 


Gain,  6  oz- 


-i 


calories 


30  calories 


Divide  into  10  bottles.    Feed  3 
oz.  every  2  hours  as  before. 


330  calories,  or  55+  per  pound. 

The  food  was  unchanged  at  this  date  because  there  had  been  a  gain  in 
weight  and  because  it  was  thought  best  to  go  slowly  and  not  create  any  digestive 
disturbance,  the  caloric  requirements  now  being  nearly  fulfilled. 
June  15    (4  days  later)  :     Weight,  6  Ib.  4  oz. 
General  Condition.  —  Improved.  Gain,  5  oz. 

Stools.  —  Three  or  four  normal. 
Vomiting.  —  None. 
Appetite.  —  Good. 
Sleep.  —  Good. 
Treatment.  —  Food  prescribed  : 

300  calories       Divide  into  10  bottles.     Feed  3 


Milk  ..........   15  <«• 

Water  .........   15  oz 

Dextri-maltose.    %  oz. 


•) 
.j 


oz.  every  2  hours  as  before. 


60  calories 


360  calories,  or  58  per  pound. 


LOSS  OF  APPETITE  219 

June  22   (7  days  later) :     Weight,  6  Ib.  10  oz. 

Gain,  6  oz. 

General  Condition. — The  same. 
Stools. — One  normal. 
Vomitin  g. — None. 
Appetite. — Good. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Milk 15  oz.|  300  calories      Divide  into  10  bottles.    Feed  3 

Water 15  oz.J  oz.  every  2  hours  as  before. 

Dextri-maltose.   %  oz.  90  calories 

390  calories,  or  50-  per  pound- 

With  this  cautious  increase  in  sugar,  which  was  eventually  supplemented 
with  a  gradual  increase  in  the  strength  of  the  food,  this  infant  continued  to  do 
well. 

(4)  Sore  Mouth  or  Throat. — Many  an  infant  refuses  its 
food  solely  because  the  act  of  swallowing  is  painful.  An 
ulceration  or  abrasion  in  the  mucous  membrane  or  even  a 
severe  stomatitis  will  often  go  unobserved  unless  a  careful 
examination  of  the  mouth  and  throat  is  made.  Teething, 
when  accompanied  by  much  swelling  and  redness  of  the 
gums,  is  commonly  the  cause  of  poor  appetite.  Cleft  palate 
and  other  congenital  anomalies  of  the  mouth  and  throat 
must  not  be  overlooked  when  new-born  infants  fail  to 
suckle  properly. 


CHAPTER  XVII 

BREAST  FEEDING 

THAT  mothers  of  the  present  day  do  not  wish  to  nurse 
their  infants  and  are  anxious  to  avoid  this  duty  is  a  mis- 
taken idea.  The  author  can  think  of  only  a  few  cases  where 
a  mother  with  a  good  supply  of  milk  has  been  unwilling 
to  nurse  her  baby.  The  majority  of  mothers  are  not  only 
anxious  to  nurse  their  infants,  but  are  extremely  disap- 
pointed if  they  find  that  they  have  not  milk  enough  to 
properly  nourish  them. 

Whether  a  physical  inability  to  supply  proper  breast 
milk  is  increasing  among  women  in  this  country  is  a  ques- 
tion which  the  general  practitioner  is  in  a  better  position 
to  decide  than  the  pediatrician.  The  latter  is  called  upon 
to  treat  the  infant  who  is  not  doing  well,  the  result  usually 
of  the  breast  milk  supply  having  failed.  It  is  a  peculiar 
fact,  though,  that  many  women  of  splendid  physique  have 
practically  no  breast  milk  even  after  repeated  pregnancies, 
while  small,  frail  women  are  frequently  seen  to  have  an 
abundant  flow  of  milk  with  correspondingly  robust  infants. 

SYMPTOMS  INDICATIVE  OF  SUCCESSFUL  BREAST  FEEDING 

The  following  symptoms  are  usually  indicative  of  suc- 
cessful breast  feeding: 

1.  The  infant  gains  six  or  eight  ounces  a  week  during 
the  first  six  months,  and  after  that  from  three  to  six  ounces 
a  week. 

2.  It  falls  asleep  as  soon  as  fed  or  while  feeding  and 
sleeps  twenty  hours  out  of  every  twenty-four  up  to  the 
sixth  month  of  age. 

3.  It  does  not  cry  more  than  one  hour  a  day. 

4.  It  has  from  one  to  three  normal  stools  a  day  and  no 
vomiting  or  gas. 

220 


FIG.  12.— The 


BREAST  FEEDING  221 

SYMPTOMS  INDICATIVE  OF  UNSUCCESSFUL  BREAST  FEEDING 

1.  The  infant  loses  in  weight,  ceases  to  gain  or  gains 
insufficiently. 

2.  Remains  too  long  at  the  breast. 

3.  Cries  or  frets  while  nursing. 

4.  Cries  when  taken  from  the  breast. 

5.  Has  abnormal  stools ;  and 

6.  Extreme  vomiting,  which  can  be  definitely  attributed 
to  the  breast  milk. 

Much  has  been  said  and  written  by  pediatricians,  and 
rightly  so,  concerning  the  importance  of  continuing  the 
breast  milk  in  every  case  where  it  is  possible.  The  other  side 
of  the  question,  that  of  the  advisability  of  discontinuing 
the  breast,  has  been  neglected.  Every  effort  should  be  made 
to  improve  the  breast  milk  and  to  keep  the  infant  upon  it, 
but  it  is  equally  important  to  know  when  to  supplement  the 
breast  with  the  bottle  or  to  discontinue  breast  feeding  alto- 
gether. 

CONDITIONS  UNDER  WHICH  BREAST  FEEDINGS  SHOULD  BE  CON- 
TINUED EXCLUSIVELY 

1.  Where  the  infant  is  normal  and  doing  well  upon  the 
breast. 

2.  Where  the  infant  is  not  doing  well  but  the  condition 
can  be  accounted  for  by  errors  in  the  management  of  the 
mother  or  infant,  or  by  the  health  of  the  mother. 

Under  the  second  condition  breast  feeding  should  never 
be  discontinued  suddenly.  It  is  advisable  to  keep  the  infant 
for  at  least  one  week  exclusively  upon  the  breast,  properly 
regulating  every  detail.  The  weight  should  be  taken  at  the 
beginning  of  this  period,  and  if  there  has  been  found  a  fairly 
good  gain  in  weight  during  this  trial  week  it  may  not  become 
necessary  to  institute  bottle  feedings. 

During  this  period  the  following  details  should  be  care- 
fully looked  after: 


222  SIMPLIFIED  INFANT  FEEDING 

1.  Regulating  the  mother's  diet. 

2.  Improving,  if  necessary,  the  mother's  appetite. 

3.  Regulating  the  mother's  bowels. 

4.  Regulating  other  hygienic  details,  such  as  exercise, 
sleep,  and  mental  rest. 

5.  Remedying  any  actual  disease  of  the  mother,  such 
as  anaemia,  etc. 

6.  Regulating  feeding  times  and  intervals. 

7.  Correcting  any  errors  in  detail  of  giving  breast. 

8.  Remedying  any  defects  in  the  hygienic  surroundings 
or  management  of  the  infant. 

Mother's  Diet. — Of  all  these  considerations,  perhaps  the 
most  important  is  the  diet  of  the  mother,  for  without  proper 
nourishment  for  herself  she  cannot  nourish  her  infant. 

It  has  never  been  definitely  proved  that  any  one  kind  of 
food  that  the  mother  eats  increases  any  one  element  of 
the  breast  milk,  either  fat,  sugar  or  proteid,  and  it  is  an 
academic  question,  the  importance  of  which  is  not  of  so 
much  real  consequence  as  knowing  whether  the  milk  as  a 
whole  can  be  improved  by  regulating  the  mother's  diet. 
That  breast  milk  can  be  improved  in  this  way  has  been 
demonstrated  by  an  immediate  improvement  and  gain  in 
weight  shown  in  infants  who  were  not  doing  well  before  a 
proper  diet  was  instituted  for  the  mother. 

Many  peculiar  ideas  about  the  diet  of  nursing  mothers 
are  found  among  the  laity,  and  in  each  part  of  the  country 
various  notions  obtain.  For  instance,  along  certain  parts 
of  the  coast,  fish  is  supposed  to  be  most  deadly  both  to  the 
mother  and  infant  during  the  nursing  period.  Almost  uni- 
versally vegetables  and  fruits  are  denied  nursing  mothers 
on  account  of  possible  injurious  effects  upon  the  infant.  The 
vegetarian  believes  that  no  meat  should  be  eaten  during 
this  period.  All  of  these  theories,  however,  have  no  foun- 
dation in  fact  and  are  harmful,  in  that  they  restrict  the 
mother's  diet  at  a  time  when  she  most  needs  nourishment. 


BEEAST  FEEDING  223 

There  may  be  a  few  of  the  highly  flavored  fruits  and 
vegetables  that  give  rise  to  colic  in  the  infant,  but  usually 
the  absence  of  fruit  and  vegetables  from  the  diet  serves 
only  to  cause  constipation  in  the  mother  and  often  in  the 
infant.  Meat  is  particularly  beneficial  in  increasing  the 
quality  and  quantity  of  the  milk,  and  three  hearty  meals  a 
day,  with  meat  twice  and  eggs  at  the  other  meal,  are  advisa- 
ble where  an  effort  is  being  made  to  increase  the  breast  milk 
supply.  A  diet  that  agrees  best  with  both  mother  and  infant 
during  the  nursing  period  is  one  to  which  she  has  become 
accustomed  before  pregnancy,  provided  it  has  been  a  proper 
and  sensible  one  and  did  not  cause  indigestion. 

An  error  common  to  physicians  and  the  laity  is  that  of 
giving  too  much  milk  or  other  fluids  between  meals.  These 
fluids  lessen  the  desire  for  the  regular  meals  and  should  not 
be  given  to  the  exclusion  of  the  three  regular  meals  of  the 
day.  Case  LI  is  a  good  illustration  of  this  excessive  fluid 
diet.  In  this  case  four  quarts  of  malted  milk  were  taken 
between  meals,  besides  milk,  milk  soups,  and  other  fluids  at 
meal  times. 

CASE  LI 

(Illustrating  the  effect  of  mother's  overfeeding  and  its  control) 
March  8:     Age,  5  months.     Birth  weight,  5  Ib.  8  oz. 

Present  weight,  16  Ib.  3  oz. 
Gain  since  birth,  10  Ib.  11  oz. 
General  Condition. — Excellent;    fat,   well  developed,  good  color,  skin  smooth 

except  for  patches  of  eczema  on  the  face  and  hands. 
Stools. — Since  birth  two  or  three  a  day,  sometimes  green,  watery,  and  with 

mucus. 

Vomiting. — A  few  mouthfuls  after  each  feeding. 
Appetite. — Refuses  breast  at  times. 
Sleep. — Restless  at  night. 
Temperature,  98.6°  F. 

Chief  Complaint. — Has  frequent  colic  and  some  vomiting;  cries  a  great  deal. 

Previous  Food. — Breast  milk  exclusively.     Fed  every  three  or  three  and  a 

half  hours,  seven  feedings   in  twenty-four   hours.     No   regular  intervals 

of  nursing.     Mother  eats  three  hearty  meals  a  day,  leside  cream  soups, 

tea  and  cocoa,  and  four  quarts  of  ~tnalted  milk  between  meals.    With  this 


224  SIMPLIFIED  INFANT  FEEDING 

forced  diet  she  has  increased  her  own  weight  since  the  birth  of  the  infant 
from  105  pounds  to  145  pounds. 

Treatment. —  (For  mother.)  Stop  all  liquids  between  meals  except  water. 
Eat  three  hearty  meals  a  day,  but  no  more  than  the  appetite  demands. 
(For  infant.)  Feed  every  three  hours  at  6,  9,  12  A.M.,  and  3,  6,  9  P.M., 
omitting  the  9  P.M.  feeding  if  the  infant  will  sleep  through  the  night  with- 
out it. 

March  22    (2  weeks  later) :     Weight,  16  Ib.  8  oz. 

Gain,  5  oz. 

General  Condition. — The  same,  except  that  the  eczema  has  disappeared. 

Stools. — One  yellow,  normal  stool  vrith  no  mucus. 

Vomiting. — None. 

Appetite. — Nurses  well  for  ten  minutes. 

Sleep. — From  6  P.M.  to  6  A.M.,  an  hour  in  the  morning  and  two  hours  in  the 
afternoon. 
This  infant  continued  to  do  well,  and,  although  it  did  not  increase  its 

weight  rapidly   (which,  on  the  whole,  was  an  advantage),  it  had  much  less 

indigestion  and  slept  much  better  after  the  mother's  diet  was  reduced. 

If  the  appetite  is  good  at  the  three  regular  meals,  and 
if  the  mother  also  feels  the  need  of  nourishment  during  the 
interval,  she  may  take  a  cup  of  some  fluid  nourishment  be- 
tween breakfast  and  luncheon,  in  the  middle  of  the  afternoon, 
and  before  retiring  at  night,  but  this  should  be  discontinued 
when  it  is  seen  to  interfere  with  the  regular  meals. 

In  obtaining  a  history  of  the  diet  it  is  well  to  review  the 
events  of  the  present  day,  asking  the  following  questions : 
What  did  you  eat  for  breakfast  f  What  did  you  eat  at  the 
noon  meal?  What  did  you  eat  at  night?  What  do  you  take 
between  meals  ?  How  much  milk  or  other  fluids  do  you  take 
in  the  twenty-four  hours  ? 

It  is  an  American  custom  to  take  one  very  hearty  meal  a 
day,  either  in  the  evening  or  at  noon,  and  to  neglect  the 
other  two  meals.  Breakfast  is  apt  to  be  light  from  habit  or 
because  of  lack  of  appetite  on  rising  in  the  morning;  and 
in  families  where  it  is  the  custom  to  have  the  hearty  meal 
at  night  to  accommodate  the  father  of  the  family,  the  busy 


BREAST  FEEDING  225 

housewife  very  generally  neglects  her  noonday  meal.  The 
result  is  underfeeding  of  the  mother  and,  in  many  instances, 
of  the  infant.  A  mother  should  be  impressed  with  the  fact 
that  for  the  infant's  sake,  if  not  for  her  own,  she  should  eat 
a  hearty  breakfast  and  a  proper  meal  at  noon. 

CASE  LII 
(Illustrating  the  effect  of  mother's  underfeeding  and  its  effect  upon  the  infant) 

October  11:     Age,  6  weeks.     Birth  weight,  6  Ib.  8  oz. 

Present  weight,  7  Ib. 
Gain  since  birth,  8  oz. 

General  Condition. — Small,  poorly  nourished,  fretful. 

Stools. — Two  or  three  small,  watery,  yellow  or  green,  some  mucus,  no  curds. 
Vomiting. — A  little  after  each  feeding. 
Appetite. — Seems  hungry  all  the  time. 
Sleep. — Poor,  night  and  day. 
Chief  Complaint. — Has  not  gained  in  weight  for  the  last  three  weeks.     Cries 

most  of  the  time. 

Previous  Food. — Breast-fed  at  irregular  intervals,  usually  once  in  two  hours, 
getting  from  two  to  four  feedings  at  night  and  as  many  as  twelve  in  twenty- 
four  hours.    The  mother's  bowels  were  normal  and  she  was  in  her  usual 
good  health,  but  had  never  been  in  the  habit  of  eating  more  than  a  roll 
and  a  cup  of  coffee  at  breakfast,  and  at  luncheon  some  soup  and  bread,  with 
occasionally  an  egg.     She  ate  a  good  dinner,   including  soup,  meat,  and 
vegetables.    Nothing  teas  taken  between  meals  except  a  cup  of  tea  or  water. 
Treatment. —  (For  mother.)     Food  prescribed: 
Breakfast:  Cereal,  one  egg,  bacon,  toast. 
Noon  and  night:  A  hearty  meal,  with  meat  and  vegetables  in  plenty  and 

a  nourishing  dessert. 
10  A.M.,  3  and  10  P.M.:  Malted  milk,  milk,  or  cocoa.     Nux  vomica  and 

gentian  for  appetite. 

(For  infant)  :   Nursing  from  the  breast  only  once  in  three  hours  at  6,  9,  12 
A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

October  16  (5  days  later)  :     Weight,  7  Ib.  12  oz. 

Gain,  12  oz. 

General  Condition. —  Much  improved. 
Stools. — Two  or  three  normal. 
Vomiting. — Much  less. 
Appetite. — Good. 
Sleep. — Good  all  night,  but  cries  a  great  deal  in  the  daytime. 

The  directions  had  been  well  carried  out,  the  routine  adhered  to,  and  the 
mother  was  eating  all  the  food  prescribed.    Treatment  continued. 
15 


226  SIMPLIFIED  INFANT  FEEDING 

October  23  (7  days  later)  :     Weight,  8  Ib.  4  oz. 

Gain,  8  oz. 

General  Condition. — Excellent. 
Stools. — Two  normal  a  day. 
Vomiting. — None. 
Appetite. — Satisfied. 
Sleep. — Most  of  the  day  and  night. 

Treatment. — With  the  exception  of  discontinuing  the  nux  vomica,  the  treatment 
remained  the  same. 

November  6   (14  days  later)  :     Weight,  9  Ib.  11  oz. 

Gain;  1  Ib.  7  oz. 

The  infant  continued  to  do  well,  and  at  six  months  of  age  was  exceptionally 
fat,  strong,  and  well,  and  still  entirely  breast-fed. 

Such  rapid  improvement  without  the  addition  of  bottle 
feedings  is  not  to  be  expected  in  cases  where  the  mother's 
milk  is  deficient  when  she  is  already  taking  the  proper 
amount  of  nourishment. 

An  excellent  diet  for  nursing  mothers  is  as  follows : 

Breakfast. — A  liberal  dish  of  cereal,  with  plenty  of  milk 
and  cream;  one  or  two  eggs  (occasionally  with  bacon) ;  toast 
or  bread,  and  a  cup  of  coffee  or  tea  if  the  mother  is  in  the 
habit  of  taking  these  beverages,  otherwise  cocoa. 

Noon  Meal. — A  liberal  piece  of  meat  or  fish;  potatoes, 
baked,  boiled,  mashed,  or  creamed,  and  at  least  one  other 
vegetable ;  a  dessert  of  fruit,  custard,  a  simple  milk-and-egg 
pudding  or  ice  cream. 

Night  Meal. — Soup  (preferably  a  creamed  soup) ;  meat 
or  fish;  potatoes,  baked,  boiled,  mashed,  or  creamed;  other 
vegetables ;  salad ;  and  a  simple  dessert,  as  at  noon  meal. 

All  indigestible  food  should  be  avoided,  such  as  pastry, 
rich  cakes,  fried  food,  and  excessive  amounts  of  candy  or 
sweets.  A  cup  of  malted  milk,  cow's  milk,  cocoa  or  a  bowl 
of  gruel  (half  milk)  may  be  taken  during  the  intervals.  Any 
of  the  vegetables  may  be  eaten,  including  cabbage,  cauli- 
flower, and  turnips  (particularly  if  the  mother  is  constipated 
and  needs  laxative  foods),  provided  they  do  not  cause  colic 
in  the  infant  or  indigestion  in  the  mother. 


BREAST  FEEDING  227 

Authorities  differ  greatly  upon  the  subject  of  alcohol 
for  nursing  mothers.  Personally  the  author  does  not  advise 
its  use  as  a  means  of  stimulating  the  breasts  to  secrete  more 
or  better  milk.  In  cases  where  some  of  the  mild  malt  liquors 
have  already  been  used  by  a  mother  and  it  has  been  demon- 
strated that  they  have  not  given  the  infant  colic,  their  use 
need  not  necessarily  be  prohibited.  The  author  recalls  one 
case  of  a  very  abstemious  woman  who  could  temporarily 
stimulate  her  breasts  to  an  abundant  supply  of  milk  by 
drinking  one  ounce  of  whiskey.  She  resorted  to  this  expedi- 
ent only  on  rare  occasions  when  her  milk  had  failed  because 
she  was  overtired  or  not  in  her  usual  good  health.  She  was 
permitted  to  use  this  method  of  stimulating  the  flow  of  milk 
on  rare  occasions,  since  it  did  not  seem  to  cause  any  dis- 
comfort to  the  infant.  There  is  no  doubt  that  alcohol,  taken 
by  the  mother,  does  give  rise  to-  indigestion  in  the  infant, 
and  in  many  infants  colic  was  controlled  after  all  alcoholic 
stimulation  had  been  stopped.  Many  cases  of  colic  are 
caused  by  a  mother  taking  a  cocktail  or  light  wine  or  even 
beer  for  her  dinner,  and  this,  too,  with  a  mother  who  had  been 
accustomed  to  such  moderate  indulgence. 

Mother's  Appetite. — It  is  needless  to  say  that  a  mother 
cannot  take  the  food  that  is  ordered  for  her  unless  she  has 
a  good  appetite.  When  the  appetite  is  poor  it  may  usually 
be  improved  by  remedying  some  error  in  her  diet.  This 
having  been  accomplished,  it  is  usually  well  to  prescribe  a 
tonic.  The  one  that  the  author  has  found  most  useful  is : 

Ifc     Tinct.  Xux  Vomica,  3v 

Tinct.  Gentian  Compound,  q.s.a.d.,  Jiv 
Da  Signa:     1  teaspoonful  in  a  quarter  of  a  glass  of 

water  three  times  a  day  before  meals. 

Mother's  Bowels. — Many  women  get  into  the  habit  of 
taking  cathartics  during  pregnancy  or  during  the  lying-in 
period,  and  a  physician  knows  how  difficult  it  is  to  overcome 
constipation  of  long  standing,  or  constipation  due  to  an 


228  SIMPLIFIED  INFANT  FEEDING 

abuse  of  cathartics.  It  is  highly  important  that  every  nurs- 
ing mother  should  have  at  least  one  good  evacuation  of  the 
bowels  each  day.  Constipation  in  a  breast-fed  infant  is 
more  frequently  due  to  constipation  in  the  mother  than  to 
any  other  cause,  and  usually  when  the  mother's  constipation 
is  overcome  the  infant's  bowels  become  normal  also.  (See 
p.  270.) 

There  are  three  methods  of  overcoming  constipation: 
dietetic  measures,  medicinal  measures,  and  enemata.  Die- 
tetic measures  should  be  tried  before  resorting  to  any  others. 
It  is  not  sufficient  to  tell  a  mother  to  eat  plenty  of  fruit  and 
vegetables  and  to  take  coarse  food,  because  such  general 
directions  are  apt  to  be  misconstrued.  It  is  necessary  to  tell 
her  to  take  vegetables  in  plenty,  both  at  her  noon  meal  and  at 
her  night  meal,  and  to  lay  particular  emphasis  upon  the  de- 
sirability of  the  coarser  vegetables,  such  as  beets,  carrots, 
green  corn,  turnips,  and  cabbage.  If  it  is  seen  that  these 
vegetables  cause  colic  in  the  infant,  they  must,  of  course, 
be  discontinued  and  medicinal  measures  resorted  to.  She 
should  also  be  told  to  take  plenty  of  fruit.  She  should  take 
fruits  with  every  meal  and  often  between  meals,  eating  each 
day  as  many  as  three  or  four  pears,  apples,  oranges,  plums, 
or  peaches  (or  other  fruit  in  season),  or  as  much  as  is 
necessary  to  make  her  bowels  move.  Prunes,  raisins,  and 
dried  fruits  may  be  taken,  but  one  tires  of  them  more  easily 
than  the  fresh  fruit  and  it  is  more  difficult  to  take  a  sufficient 
quantity.  The  constipated  mother  should  eat  the  coarser 
breads  and  cereals  in  preference  to  the  finer  ones.  Oatmeal, 
graham  bread,  rye  bread,  bran  biscuits  are  laxative. 

Medicinal  measures  consist  in  the  giving  of  a  mild  cathar- 
tic, consultingthe  mother  as  to  her  choice  so  far  as  is  feasible. 
Salts  of  any  kind  should  be  avoided,  as  they  result  in  watery 
movements  which  drain  the  body  fluids  and  tend  to  dry  up 
the  milk.  One  of  the  many  varieties  of  Eussian  oil  (liquid 
albolin,  etc.)  may  be  taken  once  or  twice  a  day  after  eating. 


BREAST  FEEDING  229 

Phenolphthalein,  3  to  5  grains  a  day,  may  be  used,  usually 
giving  1  grain  three  times  a  day.  Fluidextract  of  caseara, 
10,  15,  20,  or  25  drops  three  times  a  day  before  eating,  may 
be  used.  The  author  prefers  the  phenolphthalein  when  it  is 
necessary  to  give  a  cathartic.  Enemata  are  useful  while  the 
nursing  mother  is  still  in  bed,  or  to  give  the  bowels  the  regu- 
lar habit  of  evacuating,  when  the  laxative  diet  is  first  being 
instituted.  Either  a  plain  saline  enema  or  a  glycerine  and 
water  enema  may  be  used. 

CASK  LIU 

(Illustrating  constipation  in  an  infant  as  a  result  of  the  mother's  constipation — 
and  its  control) 

December  17:     Age,  5  weeks.     Birth  weight,  7  Ib.  8  oz. 

Present  weight,  9  Ib.  8  oz. 
Gain  since  birth,  2  Ib. 

General  Condition. — Fat,  well  nourished,  normal  infant. 
Stools. — Constipated;  bowels  move  once  a  day  with  enema. 
Vomiting. — None. 

Appetite. — Takes  breast  well  for  fifteen  minutes. 
Sleep. — Excellent. 
Temperature,  98.6°  F. 

Chief  Complaint. — Constipation;  otherwise  perfectly  well. 

Previous  Food. — Breast  milk  exclusively,  fed  every  three  hours  with  great 
regularity  (ten  to  twenty  minutes  at  the  breast),  seven  feedings  in 
twenty-four  hours.  Mother's  diet  very  good,  except  that  she  is  not  eating 
enough  vegetables  or  fruits.  Her  appetite  is  excellent,  but  her  bowels  are 
very  constipated,  moving  every  other  day  with  an  enema. 

Treatment. —  (For  mother)  Advised  to  eat  more  and  coarser  vegetables,  such 
&s  turnips,  cabbage,  beets,  carrots,  and  at  least  two  oranges  and  two 
apples  a  day  between  meals.  These  are  to  be  discontinued  if  there  are 
signs  of  the  infant  having  colic  or  discomfort.  If,  after  two  or  three  days 
of  this  diet,  the  bowels  did  not  move  of  their  own  accord,  15  drops  of  the 
fluidextract  of  cascara  were  to  be  taken  three  times  a  day  before  eating. 
December  30  (13  days  later)  :  Weight,  10  Ib.  6  oz. 

Gain,  14  oz. 

The  mother's  bowels  moved  freely  once  a  day  with  the  increased  fruit  and 
vegetables,  so  that  she  was  not  obliged  to  take  the  cathartic.  This  had  a 
decided  effect  upon  the  infant's  bowels}  which  have  moved  once  or  twice  a  day. 

Exercise,  Sleep,  and  Mental  Quiet. — There  are  women, 
whose  milk  supply  is  never  satisfactory.  Nervous,  irritable 
women  who  are  constantly  worried  are  usually  unable  to 


230  SIMPLIFIED  INFANT  FEEDING 

nurse  their  infants  successfully.  Try  as  one  may,  it  is 
usually  not  possible  to  overcome  a  temperament  of  this  sort, 
and,  although  the  mother  may  be  able  to  keep  her  infant 
on  the  breast  for  two  or  three  months,  the  infant  is  not  apt 
to  thrive  and  usually  has  an  attack  of  colic  when  anything 
happens  to  disturb  the  mother. 

CASE  LIV 

(Illustrating  effect  of  mother's  nervousness  upon  her  infant) 
July  8:     Age,  3  weeks.     Birth  weight,  8  Ib.   11   oz. 
Present  weight,  8  Ib.  13  oz. 
Gain  since  birth,  2  oz. 

General  Condition. — Only  fairly  well  nourished,  good  color,  well  developed. 

Stools. — One  or  two  per  day,  green,  watery ;  much  mucus  and  some  fine  curds. 

Vomiting. — None. 

Appetite. — Seems  hungry  all  the  time. 

Sleep. — Cries  a  great  deal  throughout  the  day  and  sleeps  only  three  hours  at 
night. 

Temperature,  99.4°  F. 

Chief  Complaint. — Crying ;  not  gaining  in  weight;  loose  stool*. 

Previous  Food. — Breast-fed  exclusively  every  three  hours  regularly,  seven 
feedings  in  twenty- four  hours;  at  the  breast  twenty  minutes  to  half  an 
hour  at  a  time.  The  mother,  who  was  under  the  care  of  a  trained  nurse, 
was  on  a  model  diet  and  eating  plenty  of  good,  nourishing  food.  Her 
bowels  were  kept  in  good  condition;  her  milk  seemed  very  plentiful,  but 
was  evidently  causing  the  infant's  loose  stools.  She  was  exceedingly  ner- 
vous about  her  infant,  worrying  when  there  was  no  occasion  to  do  so.  She 
feared  that  it  was  going  to  die,  and  one  of  her  chief  dreads  was  that  she 
would  be  the  cause  of  its  death  by  her  inability  to  furnish  proper  breast 
milk. 

Treatment. —  (For  mother)     It  was  perfectly  evident  that  this  mother  never 
could  nurse  her  baby  because  of  her  nervous  temperament.    It  was  thought 
advisable,  for  a  while  at  least,  to  allow  the  infant  to  be  put  to  the  mother's 
breast  for  only  five  minutes  at  a  time  to  satisfy  the  mother. 
(Treatment  for  the  infant)     Breast  for  five  minutes  only,  every  three 
hours,  seven  feedings  in  twenty-four  hours,  at  6,  9,  12  A.M.,  3,  6,  9  P.M., 
and  2  A.M.,  completing  the  feedings  with  3  ounces  of  the  following  mix- 
tures: milk,  7  ounces;  water,  14  ounces;  sugar,  none;  boiled  and  divided 
into  seven  feedings. 
After  two  weeks,  when  the  bottle  feedings  had  been  increased  in  strength 

and  sugar  added,  the  breast  was  discontinued  entirely  and  the  infant  progressed 

normally  on  the  bottle. 


BREAST  FEEDING  231 

A  mother  who  does  not  take  enough  exercise  to  keep 
herself  in  good  condition  cannot  expect  to  have  the  proper 
milk  for  her  infant.  For  such  women  the  amount  of  exercise 
should  be  carefully  planned  in  order  that  they  shall  not  over- 
tax their  strength  in  endeavoring  to  fill  the  general  directions 
of  "more  exercise."  A  woman  who  does  not  do  her  own 
housework  may  be  advised  to  take  the  infant  out  in  the 
carriage  for  a  walk  each  day,  sitting  down  whenever  she 
becomes  tired,  and  in  that  way  be  provided  with  an  object 
for  going  out. 

Many  women  do  not  have  sufficient  sleep,  due,  perhaps, 
to  the  infant 's  wakef ulness  at  night.  If  the  patient  is  wake- 
ful at  night,  the  mother  should  make  up  her  lost  sleep  dur- 
ing the  day.  A  physician  should  never  be  too  busy  to  give 
his  attention  to  these  details  if  he  expects  to  be  successful 
with  his  feeding  cases. 

Remedying  Any  Actual  Disease  of  the  Mother. — Many 
women  are  weak  and  anaemic  when  they  begin  to  nurse  their 
infants  following  a  difficult  labor  or  a  trying  pregnancy. 
Often  this  fact  is  not  taken  into  consideration  by  the  phy- 
sician, and  the  infant  is  abruptly  taken  from  the  breast  when 
the  mother's  condition  might  have  been  improved  and  the 
infant  allowed  to  remain  upon  the  breast.  A  timely  adminis- 
tration of  an  iron  mixture  will  usually  improve  the  anaemia 
and  thereby  increase  the  strength  and  save  the  breast  milk. 
A  neglected  perinea!  wound,  malposition  of  the  uterus,  or 
subinvolution  is  often  the  cause  of  the  loss  of  the  milk.  It 
is  often  possible  to  save  the  breast  milk  even  when  it  is  neces- 
sary to  do  a  major  operation  upon  the  mother.  The  author 
has  seen  women  go  through  such  operations  as  those  for 
gall-stones  and  appendicitis  and  still  retain  their  breast  milk. 
The  infant  need  be  taken  from  the  breast  in  some  instances 
for  only  one  day.  If  it  is  necessary  to  keep  the  infant  away 
from  the  breast  two  or  three  days,  the  breast  milk  will  not 
dry  up,  but  will  return  as  soon  as  the  infant  is  again  put 
to  the  breast.  As  a  matter  of  fact,  the  author  has  seen 


232  SIMPLIFIED  INFANT  FEEDING 

the  breast  milk  return  after  the  infant  had  been  taken  away 
for  three  weeks. 

Regulation  of  Feeding  Times  and  Intervals. — After  many 
years  of  the  two-hour  interval  plan  for  breast-fed  infants 
it  is  now  generally  conceded  that  such  intervals  are  never 
necessary  except  in  extremely  small,  undersized,  or  prema- 
ture infants.  The  average  infant  should  be  put  to  the  breast 
once  in  three  hours  during  the  daytime  and  once  at  night 
from  the  first  day  of  life  to  the  end  of  the  first  year.  For 
nursing  babies  the  day  begins  at  six  in  the  morning  and 
ends  at  nine  or  ten  at  night.  The  feedings  are  best  given  at 
a  stated  time  each  day,  and  it  is  well  to  write  out  the  hours 
when  the  infant  is  to  be  fed.  The  hours  of  6,  9, 12  A.M.,  3,  6, 
9  P.M.,  and  2  A.M.,  are  usually  most  convenient,  but  7, 10  A.M., 
1, 4, 7, 10  P.M.,  and  2  A.M.  may  be  used  if  they  fit  in  better  with 
the  family  meal  times  or  other  family  routine.  After  three 
or  four  months  of  age,  or  possibly  before,  if  the  infant  does 
it  voluntarily,  the  2  A.M.  feeding  should  be  omitted. 

Four-hour  intervals  are  preferable  for  normal,  well-nour- 
ished infants  who  are  gaining  rapidly  in  weight.  Large, 
robust  infants  whose  mothers  have  a  plentiful  supply  of 
good  breast  milk  may  be  fed  once  in  four  hours  from  birth. 
Breast-fed  infants  who  are  vomiting  or  have  colic  or  loose 
stools  should  be  fed  at  four-hour  intervals  if  they  are  gaining 
rapidly  in  weight.  The  usual  hours  are  6,  10  A.M.,  2,  6,  10 
P.M.,  and  2  A.M.  It  is  always  advisable  to  hold  to  the  same 
hours  each  day  and  to  waken  the  infant  for  the  feeding 
during  the  first  few  weeks  of  life,  when  it  first  comes  under 
treatment,  so  that  it  may  establish  habits  of  regularity, 
which  it  will  very  soon  do  with  the  proper  training.  It  is 
not  an  uncommon  experience  to  see  an  infant  that  is  fret- 
ful and  not  sleeping  properly,  that  is  not  gaining  in  weight 
or  has  digestive  disturbances,  such  as  vomiting  and  loose 
bowels,  and  where  the  whole  fault  lies  in  irregular  feed- 
ings. A  physician  should  be  most  insistent  upon  the  matter 
of  routine,  as  the  whole  success  of  his  treatment  may 


BEEAST  FEEDING  233 

rest  upon  it.  He  should  also  be  emphatic  enough  in  his  in- 
structions to  impress  the  mother  with  the  importance  of 
following  out  his  directions  minutely. 

CASE  LV 

(Illustrating  the  effect  of  regularity  of  feeding  in  improving  an  infant's  diges- 
tive disturbances) 

December  29:     Age,  2  months.     Birth  weight,  unknown. 

Present  weight,  8  Ib.  4  oz. 

General  Condition. — Well  nourished,  well  developed,  good  color,  normal  in 
every  way. 

Stools. — One  or  two  stools  a  day,  green  or  yellow,  watery,  with  some  mucus  and 
some  curds. 

Vomiting. — Two  or  three  drams  immediately  after  each  feeding. 

Appetite. — Nurses  well  five  or  ten  minutes. 

Sleep. — At  short  intervals  only,  except  from  9  P.M.  to  2  A.M. 

Temperature,  98.8°  F. 

Chief  Complaint. — Crying,  vomiting,  loose  stools. 

Previous  Food. — Breast-fed  exclusively  (except  for  sugar  and  water  feedings 
in  the  bottle)  ;  fed  whenever  it  cries.  Baby  spoiled  by  mother,  grand- 
mother, and  nurse.  The  mother's  diet  is  excellent,  her  appetite  good,  and 
her  bowels  move  once  or  twice  each  day. 

Treatment. —  (For  mother)     The  mother  was  informed  of  the  importance  of 
nursing  the  "baby  regularly,  and  advised  to  take  the  infant  away  from  the 
grandmother  and  to  get  a  different  nurse.     Feedings  were  scheduled  for 
6,  9,  12  A.M.  and  3,  6,  9  P.M. 
These  directions  were  carried  out  to  the  letter,  evidently,  for  the  colic  very 

quickly   disappeared,    the  infant's   bowels   became  normal,   and   the   vomiting 

eventually  ceased. 

Correcting  Any  Errors  in  Details  of  Giving  Breast. — A  phy- 
sician may  often  discover  mistakes  that  the  mother  is  mak- 
ing, and  occasionally  very  ridiculous  ones,  by  watching  the 
infant  during  a  feeding.  The  author  not  long  ago  asked  the 
mother  of  a  breast-fed  infant  who  was  not  doing  well  to 
nurse  her  infant  so  that  he  might  see  how  it  was  done.  The 
infant  was  six  weeks  old  and  the  mother  had  been  out  of 
bed  for  three  or  four 'weeks.  She  promptly  lay  down  upon 
the  bed  and,  leaning  over  the  infant,  nursed  it  lying  flat  upon 
its  back.  This  explained  why  the  infant  was  getting  the  food 
too  fast  and  was  therefore  vomiting  it. 

The  length  of  time  that  an  infant  should  remain  at  the 


234  SIMPLIFIED  INFANT  FEEDING 

breast  at  each  feeding,  varies  with  the  individual  mother  and 
the  individual  infant.  This  is  a  fact  which  is  not  sufficiently 
recognized.  Many  infants  get  all  the  milk  they  need  in 
five  or  six  minutes  because  the  milk  is  abundant  and  flows 
too  freely.  If  a  mother  with  an  abundant  milk  supply  is  told 
to  nurse  her  infant  for  twenty  minutes  (the  usual  instruc- 
tions) it  is  not  only  difficult  for  her  to  keep  the  infant  awake 
for  this  length  of  time,  but  it  will  also  cause  the  infant  con- 
siderable indigestion.  When  the  milk  is  less  abundant  and 
comes  slowly  the  infant  does  need  to  be  nursed  for  twenty 
minutes.  The  proper  way  is  to  nurse  the  infant  until  it  stops 
of  its  own  accord  or  perhaps  goes  to  sleep  (with  a  maximum 
of  twenty  minutes).  If  the  infant  has  not  received  enough  at 
one  feeding,  it  will  make  up  for  it  at  the  next. 

CASE  LVI 

( Illustrating  the  benefit  of  adjusting  feeding  details  to  suit  the  infant) 
August  19:     Age,  2  months.     Birth  weight,  6  Ib.  8  oz. 

Present  weight,  10  Ib.  9  oz. 
Gain  since  birth,  4  Ib.  1  oz. 

General  Condition. — Normal,  healthy,  well-nourished  infant. 
Stools. — Two  or  three  daily,  usually  normal,  but  occasionally  green  and  watery, 

with  mucus. 

Vomiting. — Occasionally  a  little. 
Appetite. — Does  not  seem  hungry. 
Sleep. — Good  at  night,  fair  during  the  day. 
Temperature,  98.6°   F. 

Chief  Complaint. — Cries  more  than  it  should,  seemingly  with  colic. 
Previous  Food. — Breast-fed  exclusively  with  great  regularity  every  three  hours, 
seven  feedings  in  twenty-four  hours.  The  mother,  having  been  instructed 
to  feed  the  infant  for  twenty  minutes,  has  made  every  effort  to  keep  it 
awake  and  nurse  it  for  this  length  of  time,  although  it  often  seemed  satis- 
fied in  five  or  six  minutes,  and  was  forced  with  difficulty  to  continue  for  the 
rest  of  the  feeding  time.  The  mother's  diet  and  appetite  were  good  and 
her  bowels  normal. 

Treatment. — The  infant  to  nurse  at  the  same  intervals  as  before  (at  6,  9,  12 
A.M.,  3,  6,  9  P.M.,  and  2  A.M.),  but  only  to  take  the  breast  until  satisfied, 
even  though  this  were  but  five  minutes. 

The  colic  and  crying  ceased  almost  immediately  when  these  orders  had 
been  carried  out.  Usually  the  infant  would  nurse  only  for  five  minutes,  occa- 
sionally for  ten,  and,  as  it  gained  the  prescribed  amount  each  week  with  these 
shorter  nursings,  it  was  evident  that  it  got  plenty  of  milk  at  this  time. 


FIG.  13. — Position  in  which  to  hold  baby  (head  higher  than  breast)  when  milk  flows  too  rapidly. 


BREAST  FEEDING  235 

It  is  never  advisable  to  nurse  from  more  than  one  breast 
at  a  feeding  except  where  two  or  more  infants  are  nursing 
the  same  mother.  The  right  and  left  breasts  should  be  used 
alternately,  as  when  both  breasts  are  drained  too  often 
(both  breasts  once  in  three  hours)  the  milk  supply  is  apt  to 
deteriorate.  If  the  infant  is  not  gaining  in  weight  and  is  not 
satisfied  with  the  milk  it  gets  from  one  breast  at  a  single 
feeding,  it  is  better  to  supplement  the  breast  with  a  bottle 
feeding. 

The  use  of  a  nipple  shield  or  the  pumping  of  the  breasts 
and  feeding  with  a  spoon  or  bottle,  although  very  useful 
temporary  expedients,  should  never  be  continued  over  any 
length  of  time.  The  act  of  sucking  stimulates  the  breasts  to 
secrete  the  proper  quality  and  quantity  of  milk.  In  cases 
where  the  infant  is  too  weak  to  nurse  the  breast,  or  shows  no 
inclination  to  do  so,  the  milk  will  soon  deteriorate  and  the 
supply  fail  unless  another  infant  can  be  used  temporarily 
to  stimulate  the  breasts  in  the  natural  way.  Sore  nipples  or 
anything  that  makes  the  nursing  painful  have  an  unfavor- 
able influence  upon  the  breast  milk.  One  occasionally  sees 
an  infant  who  has  been  nursing  from  a  nipple  shield  for 
several  weeks  because  in  the  beginning  the  nipples  were  sore 
or  because  they  were  inverted  or  small.  It  then  becomes 
necessary  to  make  the  infant  take  the  nipple  without  the 
shield,  even  though  a  day's  starvation  has  to  be  resorted  to. 

CASE  LVII 

(Illustrating  the  effect  of  using  a  nipple  shield) 
December  10:     Age,  4  weeks.     Birth  weight,  7  Ib. 

Present  weight,  7  Ib.  4  oz. 
Gain  since  birth,  4  oz. 

General  Condition. — Fairly  well  nourished,  but  evidently  underfed. 
Stools. — One  or  two  normal  per  day. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Poor. 
Temperature. — 98.6°  F. 
Chief  Complaint. — Not  gaining  in  weight;  fretfuL 


236 

Previous  Food. — Breast-fed  exclusively  once  in  three  hours,  seven  feedings  in 
twenty-four  hours.  Owing  to  inverted  nipples,  nipple  shields  were  ordered 
the  first  day  or  two  of  life.  The  infant  had  become  accustomed  to  the  large 
size  of  the  nipple  of  the  shield  and  would  not  take  the  mother's  nipples, 
although  they  had  been  drawn  out  by  the  use  of  the  shield.  The  supply 
of  breast  milk  was  evidently  diminishing  in  spite  of  the  fact  that  the 
mother's  diet  was  correct  and  all  other  details  were  properly  carried  out. 

Treatment. — It  was  advised  to  abandon  the  nipple  shield  and  put  the  infant 
directly  to  the  breast.    Though  the  mother  declared  that  this  would  be  im- 
possible, she  was  urged  to  persist  for  twenty-four  hours,  giving  the  infant 
no  other  food  during  that  time. 
These  directions  were  carried  out,  and  after  about  twelve  hours'  starvation 

the  infant  began  to  suckle  properly.     This  stimulated  the  breasts  so  that  the 

milk  tros  increased  in  quantity  with  remarkable  rapidity  and  the  supply  was 

ample  for  the  infant  for  several  months. 

Corsets  should  be  of  the  correct  height,  so  that  the  edge 
will  not  strike  the  breasts.  They  should  be  either  high 
enough  to  come  above  the  breasts  or  low  enough  to  come 
entirely  below  them.  A  very  good  nursing  corset  is  made, 
which  entirely  covers  the  breasts  with  soft  material  and 
opens  at  the  nipple  line,  so  that  the  whole  breast  may  be 
exposed  at  the  time  of  nursing.  Corsets  which  rub  upon  the 
breasts  not  only  make  them  sore  but  are  a  frequent  cause 
of  breast  abscesses. 

The  position  of  the  infant  while  nursing  should  be  a  semi- 
reclining  one,  with  the  mother  sitting  in  a  comfortable  chair 
in  the  erect  position,  the  infant  lying  upon  her  arm.  If  it 
is  found  that  the  infant  gets  the  milk  too  fast,  the  mother 
may  sit  in  a  chair  with  very  high  arms,  or  beside  a  table. 
In  this  way  she  may  rest  her  arm  high,  so  that,  as  the  infant 
lies  upon  it,  its  head  is  higher  than  the  breast  and  it  is 
obliged  to  pull  upward  upon  the  nipple.  Milk  that  comes 
too  fast  will  often  be  found  to  run  out  in  a  stream  when  the 
breast  is  hanging  down  and  the  infant  is  pulling  at  it. 

Remedying  Defects  in  the  Hygienic  Surroundings  or  Manage- 
ment of  the  Infant. — An  infant  should  have  plenty  of  fresh  air, 
be  properly  clothed,  and  made  comfortable  in  every  way,  and 
it  is  part  of  the  physician's  duty,  when  supervising  its  feed- 


BEEAST  FEEDING  237 

ing,  to  see  that  these  details  are  carried  out.  An  infant  will 
often  sleep  outdoors  when  its  sleep  is  broken  and  interrupted 
in  the  house,  and  a  plentiful  supply  of  cool  air  in  the  chamber 
at  night  is  also  conducive  to  sound  sleeping.  A  tight  belly- 
band  is  extremely  uncomfortable,  especially  when  it  slips 
up  under  the  arms,  and  should  be  discontinued  after  six 
weeks  of  age  and  a  knitted  band  with  straps  over  the 
shoulders  substituted  for  it.  Too  much  handling  is  very 
bad  for  the  infant,  and  during  the  first  five  or  six  months 
of  life  an  infant  should  be  kept  in  its  crib  or  carriage  twenty- 
two  hours  out  of  every  twenty-four,  being  taken  up  only  for 
its  bath  and  feedings.  Many  an  infant 's  indigestion  is  caused 
by  its  being  taken  into  the  mother's  bed  at  night.  The 
mother,  being  half  asleep,  does  not  notice  when  the  infant  is 
nursing  (after  she  has  become  accustomed  to  it),  and  a  habit 
of  sucking  most  of  the  night  is  easily  formed. 

EXAMINATION  OF  BREAST  MILK 

The  best  indication  of  the  quality  of  the  breast  milk  is 
the  condition  of  the  infant  who  has  been  nursing  that  breast. 
If  the  infant  is  fat  and  well  nourished,  has  solid  flesh  and 
well-formed  bones,  and  is  gaining  progressively  in  weight, 
one  may  be  satisfied  that  the  breast  milk  is  of  a  good  quality. 
If  the  infant  is  not  doing  well,  which  is  the  usual  reason  for 
wishing  to  know  the  quality  of  the  milk,  it  is  doubtless  an 
indication  that  the  milk  is  poor  in  quality  or  quantity. 

Every  mother  who  is  at  all  troubled  about  the  condition 
of  her  infant  wishes  her  breast  milk  examined.  An  examina- 
tion of  the  milk  itself  is  of  less  value  than  an  inspection  of 
the  infant.  If  breast  milk  is  examined  at  all  it  should  be 
examined  by  a  competent  chemist  in  a  well-equipped  labora- 
tory. The  quantity  of  sugar,  fat,  proteid,  salts,  and  total 
solids  should  be  determined.  The  usual  examinations  made 
by  the  physician,  which  are  unavoidably  meagre,  are  of  very 
little  service.  The  pyoscope,  an  instrument  which  is  sup- 


238  SIMPLIFIED  INFANT  FEEDING 

posed  to  estimate  the  amount  of  fat  by  the  color  of  the  milk, 
the  color  being  compared  with  a  graduated  color  disc,  is 
not  accurate  enough  to  be  of  any  service.  It  is  a  well-known 
fact  that  the  color  of  cow's  milk  varies  with  the  season,  the 
variety  of  food  taken,  and  the  breed  of  cow,  and  the  color  of 
breast  milk  also  varies  under  varying  conditions. 

A  common  error  in  the  examination  of  breast  milk  is  in 
taking  too  small  a  portion  of  it  for  examination.  A  case  is 
recalled  of  a  woman  who  brought  to  the  hospital  her  infant 
who  was  not  doing  well.  An  examination  of  her  milk  was 
ordered,  and  specimens  were  obtained  on  two  different  days. 
The  first  day  a  small  amount  of  milk  was  taken  from  the 
breast  before  the  infant  had  nursed,  which  consisted,  there- 
fore, of  the  foremilk.  A  few  days  later  the  milk  was  taken 
from  the  breast  after  the  infant  had  nursed,  this  specimen 
containing  the  rich  ' '  strippings. '  '  One  can  readily  imagine 
the  enormous  difference  in  the  reports  of  these  two  speci- 
mens of  the  same  mother's  milk.  The  first  was  so  poor  that 
the  mother  was  advised  to  institute  bottle  feedings  at  once, 
while  the  second  was  so  high  in  fat  as  to  cause  the  opinion 
that  it  was  the  root  of  all  the  infant's  digestive  disturb- 
ances, and  the  mother  was  advised  to  cut  down  her  diet  and 
shorten  the  infant's  nursings  and  to  dilute  her  milk  by 
giving  water  before  and  after  the  feedings.  This  case  is 
illustrative  of  the  absurdities  which  occur  in  the  examination 
of  breast  milk. 

It  is  a  question  whether  a  fair  sample  of  breast  milk  is 
ever  procured  by  artificial  means,  especially  where  the  milk 
supply  is  a  limited  one.  Theoretically  it  would  seem  as  if  a 
fair  average  might  be  struck  if  the  whole  breast  were 
emptied,  but  it  is  doubtful  if  the  breast  milk  that  is  milked 
out  or  taken  with  the  breast-pump  is  ever  a  fair  sample  of 
that  secreted  during  the  natural  process  of  nursing  with 
the  infant's  lips  to  the  nipples. 


BREAST  FEEDING  239 

The  author  seldom  finds  it  necessary  to  have  the  milk 
examined,  usually  being  able  to  determine  the  quality  by  the- 
progress  made  by  the  infant. 

BREAST  FEEDING  OF  NEW-BORN  INFANTS 

The  sucess  of  breast  feeding  depends  largely  upon  its 
being  properly  begun  in  the  early  days  of  life.  Occasionally 
injurious  practices  are  instituted  by  physicians  as  well  as 
by  the  laity,  that  interfere  with  successful  breast  feeding. 
Chief  among  these  is  the  custom  of  giving  water,  sugar 
and  water,  barley  gruel  and  various  milk  mixtures  or  any 
other  foods  during  the  first  days  of  life.  This  is  most  often 
done  because  the  breasts  are  not  secreting  milk  and  it  is 
imagined  that  the  infant  is  hungry. 

The  argument  is  advanced  by  those  in  favor  of  its  ad- 
ministration that  water  and  sugar  are  needed  to  prevent 
loss  in  weight  during  the  first  two  or  three  days  of  life,  when 
there  is  not  sufficient  fluid  in  the  breasts,  and  the  body  fluids 
of  the  infant  are  being  drained  off  through  the  kidneys  and 
bowels.  Another  argument  advanced  for  its  use  is  that  the 
sugar  acts  as  a  laxative  upon  the  bowels.  In  theory  these 
arguments  would  seem  reasonable,  but  as  a  matter  of  fact 
the  giving  of  sugar  and  water  does  not  prevent  the  loss  of 
weight,  the  bowels  usually  move  thoroughly  of  their  own 
accord,  and  great  harm  is  frequently  done  by  giving  water 
and  sugar,  or  water  alone,  as  it  prevents  the  infant  from 
taking  hold  of  the  breast  properly  when  it  is  time  for  it  to 
do  so.  The  stomach  being  filled  with  water,  the  infant  feels 
no  need  of  food,  and  when  put  to  the  breast  makes  no  attempt 
to  suckle. 

The  infant's  refusal  to  take  the  breast  during  the 
first  three  days  of  life  is  one  of  the  most  trying  conditions 
with  which  we  have  to  deal.  The  mother  becomes  tired  and 
upset,  her  condition  acts  unfavorably  upon  her  milk,  and 
mother,  infant,  and  physician  are  disturbed  as  a  result. 


240  SIMPLIFIED  INFANT  FEEDING 

The  more  an  infant  cries  the  more  water  it  gets  from  the 
bottle  and  the  less  willing  it  is  to  take  the  breast,  especially 
if  the  nipples  are  small,  having  become  accustomed  to  the 
larger  nipple  used  on  the  bottle.  The  sugar  which  is  given 
as  a  laxative  upsets  the  gastric  and  intestinal  digestion, 
vomiting  occurs,  and  the  stools  become  loose.  Had  nature 
intended  an  infant  to  have  other  than  the  colostrum  during 
the  first  two  or  three  days  of  life  she  would  have  assuredly 
provided  it. 

An  infant  should  be  put  to  the  breast  from  four  to  six 
hours  after  birth  and  every  four  hours  thereafter  until  the 
second  or  third  day,  when  the  three-hour  schedule  should  be 
instituted,  feeding  the  infant  seven  times  in  twenty-four 
hours,  at  6,  9,  12  A.M.,  3,  6,  9  P.M.,  and  2  A.M.  The  breasts 
are  stimulated  by  the  infant's  mouth  at  the  nipple,  and 
obstetricians  assert  that  proper  contractions  of  the  uterus 
are  brought  about  by  the  act  of  nursing.  Habits  of  regu- 
larity are  established  early,  and  a  plentiful  amount  of  sleep 
for  the  infant  insured,  with  rest  and  quiet  for  the  mother. 

It  is  not  advisable  to  give  any  active  cathartics  or  salts 
to  the  mother  during  the  early  days  of  the  infant's  life. 
Salts  are  particularly  harmful,  as  they  tend  to  dry  up  the 
milk. 

As  soon  as  the  infant  has  learned  to  take  the  breast  well 
and  is  nursing  vigorously,  unsweetened  water  may  be  given 
after  a  nursing  if  the  infant  cries  and  if  there  seems  to  be  in- 
sufficient colostrum  secreted  by  the  breasts.  Sugar  and  water 
should  never  be  given;  in  fact,  even  if  the  breasts  were  to 
fail  entirely  and  the  infant  had  to  be  put  upon  the  bottle, 
the  sugar  is  best  omitted  from  the  bottle  feedings  for  the 
first  few  days. 

On  the  second  or  third  day  the  breasts  become  distended 
and  the  milk  comes  in  very  quickly.  If  there  is  no  milk  by 
the  beginning  of  the  fourth  day,  the  breast  remaining  flat 
and  empty,  bottle  feedings  should  be  begun  at  once. 


BREAST  FEEDING  241 

A  most  objectionable  custom  is  the  giving  of  a  dose  of 
calomel  to  new-born  infants  because  of  excessive  crying, 
thin  mucous  stools,  or  jaundice.  It  is  assumed  that  the 
infant  has  colic,  and  the  universal  panacea  for  colic  is  calo- 
mel. The  chances  are  equal,  however,  that  the  crying  is  due 
to  hunger  or  discomfort  from  some  other  source.  The  stools 
of  a  new-born  infant  are  almost  always,  as  soon  as  the 
meconium  has  disappeared,  thin  and  watery  and  contain 
mucus  and  a  few  fine  curds.  They  may  be  green  even  in  an 
infant  making  a  normal  progress.  Jaundice  occurs  in  at 
least  one-third  of  all  new-born  infants.  It  comes  on  from 
the  third  to  the  fifth  day  of  life,  and  is  rarely  seen  the  first 
day  or  seldom  known  to  appear  after  the  sixth  day.  The 
average  duration  of  mild  cases  is  from  three  to  four  days.  In 
severe  cases  it  may  last  from  one  to  two  weeks.  The  causes 
of  jaundice  are  varied.  In  its  simple  form  it  is  supposed 
to  be  due  to  a  too  active  secretion  of  bile  soon  after  birth, 
resulting  in  an  overflow  into  the  lymph  and  blood-vessels. 
More  severe  cases  are  due  to  a  pyogenic  infection,  congeni- 
tal malformation  of  the  bile-duct,  or  interstitial  hepatitis. 
Calomel  is  not  indicated  in  the  jaundice  of  new-born  infants. 

INDIGESTION  IN  NURSING  INFANTS  WHO  ARE  GAINING  WELL 

IN  WEIGHT 

There  is  a  class  of  infants  who,  although  they  are  gaining 
progressively  in  weight,  cry  a  great  deal,  expel  a  great  deal 
of  gas,  and  perhaps  have  a  green  stool  now  and  then.  It  is 
almost  criminal  to  take  such  infants  off  the  breast,  although 
the  temptation  to  do  so  is  very  great,  because  of  the  worry 
they  cause  the  mother  and  the  consequent  harassing  of  the 
physician.  Such  an  infant  will  frequently  cry  for  six,  eight, 
ten,  or  twelve  hours  out  of  the  twenty-four,  and  still  make 
a  good  gain  in  weight  each  week,  in  which  case  it  is  very 
probable  that  the  infant  is  being  overfed  and  the  food  supply 
should  be  reduced. 

16 


242  SIMPLIFIED  INFANT  FEEDING 

There  are  two  ways  of  diminishing  an  infant's  food 
supply:  First,  by  limiting  the  mother's  diet,  and,  second, 
by  shortening  the  length  of  the  feeding  time.  If  the  mother 
is  drinking  large  quantities  of  liquid  nourishment  either 
between  meals  or  with  her  meals,  this  should  be  stopped  or 
limited  to  a  small  amount.  Beside  this,  solid  food  may  be 
restricted  to  a  certain  extent,  stopping,  particularly,  the 
richer  foods,  such  as  sweets  and  pastry.  Alcohol  should  be 
prohibited.  Highly-flavored  fruits  and  vegetables  and 
highly-seasoned  food  may  give  rise  to  harmful  substances  in 
the  milk  and  should  be  temporarily  eliminated  from  the  diet. 
The  writer  would  include  among  these  highly-flavored  and 
seasoned  foods  asparagus,  cabbage,  cauliflower,  turnips, 
Brussels  sprouts,  peppers,  parsnips,  and  all  vegetables  eaten 
raw,  such  as  cucumbers,  radishes,  lettuce,  and  onions. 

The  second  method,  that  of  cutting  down  the  food  supply 
by  means  of  shortening  the  feedings,  should  only  be  used 
with  infants  who  are  gaining  very  rapidly  (over  eight  ounces 
a  week).  The  infant  should  be  fed  once  in  three  hours  from 
6  A.M.  to  9  P.M.,  and  if  possible  the  2  A.M.  feeding  should 
be  omitted.  The  feedings  should  at  first  be  limited  to  five 
minutes,  gradually  increasing  this  length  of  time  as  the 
infant's  symptoms  improve.  The  same  object  is  attained 
by  lengthening  the  interval  to  four  hours,  feeding  the  infant 
for  twenty  minutes  at  6,  10  A.M.,  2,  6, 10  P.M.  If  there  is  no 
improvement  in  the  symptoms  and  the  infant  does  not  gain 
normally  in  weight  under  such  treatment,  it  is  advisable 
gradually  to  increase  the  mother's  diet  again  without  ex- 
cesses and  to  return  to  the  longer  nursings  or  the  shorter 
intervals,  giving  enough  to  satisfy  the  infant  at  each  feeding. 
The  futility  of  medicinal  treatment  such  as  pepsin  and 
the  other  digestive  ferments  is  perfectly  evident  to  those  of 
open  minds  who  have  tried  them.  Mothers  will  usually 
implore  a  physician  to  give  some  medication  to  stop  the  cry- 


BEEAST  FEEDING  243 

ing,  but  if  he  does  so  in  order  to  pacify  the  mother  he  must 
realize  that  he  is  not  helping  the  condition,  and  must  be 
careful  not  to  give  such  medication  as  syrupy  mixtures  or 
opiates,  that  would  be  harmful  to  the  infant. 

CASE  LVIII 

^Illustrating  the  relief  from  colic  obtained  by  shortening  the  feedings) 
August  25:     Age,  2  months.     Birth  weight,  8  Ib. 

Present  weight,  10  Ib.  4  oz. 
Gain  since  birth,  2  Ib.  4  oz. 
General  Condition. — Fat,  normal  infant. 

Stools. — One  or  two  normal  daily,  occasionally  green  and  watery. 
Vomiting. — A  little  occasionally. 
Sleep. — Some  days  fairly  good;  other  days  cries  all  day  with  the  exception  of 

from  fifteen  minutes  to  half  an  hour,  and  often,  after  sleeping  well  during 

the  day,  cries  all  night. 
Temperature,  98.6°  F. 
Chief  Complaint.' — Crying,  colic,  gas. 
Previous  Food. — Breast-fed  exclusively  with  great  regularity  every  three  hours, 

seven  feedings  in  twenty-four  hours.     Usually  nurses  from  fifteen  to  twenty 

minutes;   would  nurse  longer  if  allowed  on  the  days,  when  it  has  colic. 

The  mother's  diet  is  a  very  liberal  one:  three  hearty  meals  a  day,  with 

plenty  of  summer  vegetables  and  fruits  which  she  had  been  urged  to  eat 

on  account  of  her  previously  constipated  bowels,  which  now  move  once  a 

day,  with  the  occasional  aid  of  phenolphthalein. 
Treatment. — To*  be  nursed  for  five  minutes  only  every  three  hours  at  6,  9,  12 

A.M.,  and  3,  6,  9  P.M.,  omitting  the  2  A.M.  feeding. 

With  this  treatment  the  colic  stopped  almost  at  once  and  the  infant  slept 
twenty  to  twenty-two  hours  out  of  the  twenty-four.  The  infant's  feedings  were 
gradually  lengthened  to  ten  minutes. 


CHAPTER  XVIH 

COMBINED  BREAST  AND  BOTTLE  FEEDING 

INDICATIONS  FOB  COMPLEMENTING  THE  BBEAST  WITH  ARTI- 
FICIAL FEEDINGS 

WHEN  everything  possible  has  been  done  to  improve  the 
quality  and  quantity  of  the  breast  milk  (see  Chapter  XVII) 
and  there  is  still  an  insufficient  gain  in  weight  or  the  infant 
cries  a  great  deal  with  hunger,  it  becomes  necessary  to 
add  bottle  feedings.  How  long  a  trial  should  be  made  before 
starting  the  bottle  must  depend  upon  the  gain  in  weight 
and  the  extent  of  the  general  improvement  during  the  first 
trial  week.  A  breast-fed  infant  who  is  doing  well  should 
gain  six  or  eight  ounces  a  week  during  the  first  six  months 
of  life.  Where  an  infant  has  not  gained  before  being  brought 
for  treatment,  and  a  three-  or  four-ounce  gain  is  made  during 
the  first  trial  week,  with  a  general  improvement  in  all  of  the 
symptoms,  we  may  reasonably  expect  a  still  greater  im- 
provement during  the  second  week,  and  accordingly  delay 
the  bottle  feedings  for  another  week. 

Where  an  infant  has  gained  slowly  before  coming  for 
treatment  (two  to  four  ounces  a  week  over  a  period  of  at 
least  four  or  five  weeks),  and  if  no  greater  gain  is  shown 
during  the  trial  week,  the  complemental  feedings  should  be 
instituted  at  once.  Where  an  infant  has  not  improved  at  all 
or  has  made  no  appreciable  gain  in  weight  during  the  first 
trial  week,  there  is  no  indication  for  delaying  the  bottle 
feedings  longer.  When,  from  the  emaciated  condition  of 
the  infant,  it  is  evident  at  first  sight  that  the  milk  is  ex- 
tremely deficient,  a  trial  week  is  not  necessary  and  bottle 
feedings  must  be  instituted  at  once.  This  is  particularly 
indicated  in  cases  where  the  mother's  diet  has  been  correct, 
the  hours  of  feeding  have  been  fairly  regular,  and  the  princi- 
pal details  carefully  carried  out  as  indicated  in  the  previous 

244 


BREAST  AND  BOTTLE  FEEDING  245 

chapter.  Case  LIX  shows  this  very  nicely,  it  being  evident 
at  the  first  visit  that  complemental  feedings  must  at  once 
be  instituted. 

CASE  LIX 
(Illustrating  the  immediate  necessity  of  complemental  feedings  for  emaciation) 

April  29 :     Age,  2  months  2  weeks.     Birth  weight,  5  Ib.  6  oz. 

Present  weight,  6  Ib. 
Gain  since  birth,  10  oz. 

General  Condition. — Pale,  extremely  emaciated,  undersized,  feeble  cry. 

Stools. — One  small,  watery  stool  with  mucus  (from  underfeeding). 

Vomiting. — None. 

Appetite. — Hungry. 

Sleep. — Fair ;  cries  most  of  the  day  and  night. 

Temperature,  97°  F. 

Chief  Complaint. — Emaciation,  crying. 

Previous  Food. — Breast-fed  exclusively  every  two  and  a  half  hours,  seven  or 
eight  feedings  in  twenty-four  hours.  Stays  at  breast  half  an  hour  or 
longer.  Mother's  diet  is  correct,  her  appetite  good,  and  her  bowels  normal. 

Treatment. — Give  seven  feedings  from  the  breast,  of  ten  minutes  each,  com- 
pleting each  feeding  with  3  ounces  from  the  bottle,  using  the  following 
formula : 

Milk    7  oz.  |  Divide  into   7   bottles.     Feed   at 

Water  14  oz.  j  b  6,  9,  12  A.M.,  3,  6,  9  P.M.,  and 

Sugar 0  2   A.M. 

Each  day  increase  the  milk  one  ounce,  allowing  the  amount  of  water  to 

remain  the  same  until  the  formula  is: 

Milk    .  .    14  oz. 


.  ) 
.  ( 
Sugar  ..................................     0 


Water  ..................................    14  oz.      bolkd 


May  6    (7  days  later)  :     Weight,  6  Ib.  8  oz. 

Gain,  8  oz. 

General  Condition.  —  Slightly  improved. 
Stools.  —  One  constipated,  with  enema. 
Vomiting.  —  None. 

Appetite.  —  Good  ;  takes  all  the  food. 
Sleep.  —  Good  at  night,  restless  during  the  day. 
Treatment.  —  Food  prescribed: 

Milk    ..........    14  oz.  |  Divide    into    7    feedings    of    4- 

Water   .........    14  oz.  J  ounces  each.     Feed  at  6,  9,  12 

Sugar  .........     0  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

after    each    ten-minute    breast 
feeding. 

May  15   (9  days  later)  :     Weight,  7  Ib.  3  oz. 
Gain,  11  oz. 


246  SIMPLIFIED  INFANT  FEEDING 

General  Condition. — Greatly  improved. 

8tools. — One  constipated. 

Vomiting. — None. 

Appetite. — Good;  leaves  no  food. 

Sleep. — Good. 

Treatment. — Food  prescribed:    as  above. 

The  infant  was  gaining  so  rapidly  that  it  was  not  thought  best  to  increase 
the  food.  Reckoning  calories  would  not  help  us,  because  it  was  not  known 
how  many  calories  the  breast  milk  contained.  The  infant's  caloric  needs 
are  420  (7  X  60 ) ,  though  it  is  known  to  be  getting  from  the  above 
formula  only  280  calories. 

The  breast  milk  was  continued  throughout  the  summer.  The  artificial 
feedings  were  gradually  increased  and  sugar  added,  and  on  September  21  the 
infant  weighed  14  pounds  9  ounces. 

When  the  breast  milk  is  deficient,  it  is  generally  advisable 
to  give  an  infant  all  the  breast  milk  that  there  is,  as  a  little 
breast  milk  is  better  than  none  and  helps  -digest  an  artificial 
feeding  when  the  two  are  given  together. 

There  is  always  the  possibility,  of  course,  of  an  infant's 
voluntarily  giving  up  the  breast  for  the  bottle  once  the 
bottle  feedings  are  instituted,  the  infant  in  many  instances 
preferring  the  bottle  to  the  breast.  This  difficulty  may  be 
obviated  to  a  certain  extent  by  putting  no  sugar  in  the  bottle 
feedings  and  by  using  the  complemental  instead  of  the  sup- 
plemental feedings. 

By  supplemental  feedings  we  mean  entire  breast  feedings 
at  certain  hours,  alternating  with  entire  bottle  feedings  at 
other  hours.  With  complemental  feedings,  each  breast  feed- 
ing is  complemented  or  made  complete  with  a  bottle  feeding 
given  immediately  after. 

The  author  has  tried  both  methods  thoroughly  and  is 
heartily  in  favor  of  complemental  feedings  (combining 
bottle  and  breast  at  each  feeding),  except  in  cases  where 
it  is  intended  to  wean  the  infant  from  the  breast.  With 
complemental  feedings 

1.  The  infant  does  not  neglect  the  breast  so  readily 
and  wean  itself. 


247 

2.  The  infant  is  evenly  fed,  not  being  underfed  at  one 
feeding  and  overfed  at  another. 

3.  The  breasts  are  stimulated  by  being  emptied  at  regu- 
lar intervals,  not  too  far  apart.    Too  long  intervals  between 
breast  feedings  will  cause  the  breast  milk  to  deteriorate. 

CASE  LX 

(Illustrating  complemental  feedings  for  underfeeding) 
May  16:     Age,  4  months.     Birth  weight,  7  Ib.  8  oz. 

Present  weight,  11  Ib.  8  oz. 
Gain  since  birth,  4  Ib. 

General  Condition. — Poorly  nourished,  well  developed,  pale. 
Stools. — One  constipated,  yellow,  per  day,  no  mucus  or  curds. 
Vomiting. — Xone. 

Appetite. — Seems  hungry  all  the  time. 
Sleep. — Good. 
Temperature,  98.6°  F. 

Chief  Complaint. — Not  gaining  properly  in  weight  for  the  last  two  months. 
Previous  Food. — Breast-fed  exclusively  once  in  three  hours,  five  feedings  in 
twenty-four  hours.     Mother's  diet  excellent  and  her  appetite  and  bowels 
normal. 

Treatment. — Advised  to  nurse  only  ten  minutes  from  the  breast  every  three 
hours  at  6,  9,  12  A.M.  and  3,  6,  9  P.M.,  six  feedings  in  twenty-four  hours, 
each  breast  feeding  to  be  completed  by  a  bottle  containing  the  following 
formula  (divided  into  six  portions)  : 

Milk   .  10  oz.  ) 

Water 20  oz.  j"  boiled 

Cane   sugar    *4  oz. 

Increase  the  milk  one  ounce  each  day,  keeping  the  amount  of  water  con- 
stant, up  to  half  milk  and  half  water. 

May  27    (11  days  later)  :     Weight,  12  Ib.  8  oz. 

Gain,  1  Ib. 

General  Condition. — Much  improved. 
Stools. — One  normal  a  day. 
Vomiting. — None. 
Appetite. — Still  hungry. 
Sleep. — Excellent. 
Treatment. — Food  prescribed: 

Milk    .  . . .   20  oz.  )  Divide    into    six    feedings    of    1- 

\     VlQllpQ 

Water   20  oz.  f  ounces  each.     Feed  every  three 

Cane  sugar %  oz.  hours  at  6,  9,  12  A.M.  and  3,  6, 

9  P.M.     To  complete  each  ten- 
minute  breast  feeding. 

The  milk  and  sugar  were  gradually  increased,  and  on  September  16  the 
infant  weighed  18  pounds. 


248  SIMPLIFIED  INFANT  FEEDING 

In  giving  directions  for  a  complemental  feeding,  the 
physician  should  instruct  the  mother  to  prepare  the  required 
number  of  bottles  every  day  according  to  the  directions  given 
in  the  chapter  on  "Bottle  Feeding."  Before  beginning  the 
nursing  the  bottle  should  be  warmed,  ready  to  give  immedi- 
ately after  the  breast  feeding  is  finished.  The  length  of 
time  that  the  infant  should  be  allowed  to  remain  at  the  breast 
before  giving  it  the  feeding  from  the  bottle  varies  with  the 
quantity  of  milk  the  breast  is  secreting.  Usually  the  mother 
is  able  to  tell  when  the  breast  is  empty  by  the  pulling  sensa- 
tion felt  when  the  infant  is  sucking  upon  an  empty  breast  or 
by  the  fact  that  the  infant  becomes  restless  and  refuses  to 
nurse.  It  is  seldom  advisable  to  give  the  breast  for  more 
than  ten  minutes  when  complemental  feedings  are  used, 
and  five  minutes  is  usually  all  that  is  necessary.  Only  one 
breast  should  ever  be  given  at  a  feeding  when  the  comple- 
mental feedings  are  used.  Three-hour  intervals  between 
feedings  are  usually  advisable,  at  6,  9, 12  A.M.  and  3,  6,  9  P.M. 
Until  the  infant  is  four  or  five  months  of  age  a  2  A.M.  feeding 
may  be  given,  and  this  entirely  from  the  breast,  as  it  will 
usually  secrete  enough  to  satisfy  the  infant  until  the  morning 
feeding,  thus  obviating  the  necessity  of  the  mother's  getting 
up  in  the  night  to  warm  the  bottle. 

Gauging  the  Strength  of  the  Food. — In  deciding  upon  the 
food  to  give  with  breast  milk  it  is  not  practicable  to  reckon 
the  amount  in  calories,  the  exact  number  of  calories  in  the 
breast  milk  taken  in  twenty-four  hours  not  being  known. 
For  a  week  or  two  it  is  advisable  to  begin  with  one-third 
milk  and  two-thirds  water,  without  sugar,  boiling  the  milk 
and  water  together.  If  this  is  well  borne  during  the  first 
week  and  there  is  a  gain  in  weight,  the  milk  can  be  increased 
one  ounce  at  a  time  until  half  milk  and  half  water  are  given 
during  the  second  week.  This  increase  may  be  advis- 
able during  the  first  week  in  cases  where  the  breast  milk 
is  very  deficient. 


BREAST  AND  BOTTLE  FEEDING  249 

It  is  usually  unnecessary  to  put  sugar  into  the  food 
during  the  first  week,  but  it  may  be  added  during  the  second 
week  if  there  has  not  been  a  sufficient  gain  in  weight  and 
provided  the  infant's  stools  are  not  loose  and  there  is  no 
excessive  vomiting.  On  the  other  hand,  sugar  is  often  un- 
necessary for  a  number  of  weeks  when  the  breast  milk  is 
fairly  good  and  if  there  is  a  good  normal  gain  of  six  or  eight 
ounces  each  week  without  it.  Some  breast  milks  are  found 
to  be  very  rich  in  sugar,  even  though  poor  in  fat  and  protein, 
in  which  case  there  is  sugar  enough  in  the  breast  milk  itself 
to  make  it  unnecessary  to  add  artificial  sugar  to  the  food. 
When  it  becomes  necessary  to  add  sugar,  as  shown  by  an 
insufficient  gain  in  weight  or  pronounced  constipation,  it  is 
well  to  begin  with  one-quarter  of  an  ounce  in  twenty-four 
hours  and  gradually  increase  this  to  one  or  one  and  a  half 
ounces.  The  quantity  of  bottle  feeding  to  be  given  at  a  feed- 
ing is  also  problematical,  as  the  quantity  of  the  breast  milk 
taken  cannot  be  accurately  measured.  A  good  plan  is  to 
make  up  enough  food  so  that  the  infant  may  have  after  each 
breast  feeding  as  many  ounces  of  artificial  food  as  it  is 
months  of  age.  If  all  of  this  is  not  taken,  no  harm  is  done. 


CHAPTER  XIX 

CONTRA-INDICATIONS  FOR  BREAST  FEEDING 

IT  is  usually  wise  to  make  an  attempt  to  nurse  the  infant 
during  the  first  week  of  life,  no  matter  how  discouraging 
the  outlook  may  be.  The  breast  must  never  be  discontinued 
where  it  is  in  any  way  possible  to  avoid  it. 

There  are  seven  contra-indications  for  breast  feeding : 

1.  When  at  two  previous  births  the  mother  has  been 
unsuccessful  in  nursing  the  infant  under  the  proper  con- 
ditions and  intelligent  care. 

2.  Where  the  mother  has  puerperal  convulsions. 

3.  Where  the  infant  has  severe  prolonged  gastric  or 
intestinal  indigestion  associated  with  loss   in  weight  or 
cessation  of  gain. 

4.  Where  the  mother  is  pregnant. 

5.  Where  the  mother  has  some  prolonged  acute  infectious 
disease,  as  typhoid  fever  or  pneumonia. 

6.  Where  the  mother  has  tuberculosis   (pulmonary  or 
localized  elsewhere),  epilepsy,  nephritis,  any  malignant  dis- 
ease, primary  anaemia  or  severe  secondary  anaemia,  or  where 
the  mother  or  the  infant  has  contracted  syphilis  after  the 
infant's  birth. 

7.  Infants  over  one  year  of  age. 

Severe  Prolonged  Gastric  and  Intestinal  Indigestion. — Occa- 
sionally a  breast  milk  is  injurious  and  harmful  and  the  cause 
of  severe  gastric  and  intestinal  indigestion.  Such  instances 
are  few  in  number,  it  being  the  rule,  with  few  exceptions, 
that  a  little  breast  milk  is  better  than  none.  But  even  in 
these  cases,  before  discontinuing  the  breast  it  is  well  to 
see  whether  a  correction  of  the  diet  and  a  proper  regula- 
tion of  the  various  details  of  breast  feeding  will  not  make 

250 


51 


CONTRA-INDICATIONS:  BREAST  FEEDING   25 

it  unnecessary  to  stop  the  breast  feeding.  If,  after  these 
errors  are  rectified,  the  infant  continues  to  vomit  and  does 
not  gain,  or  is  losing  in  weight,  and  we  are  convinced  that 
the  vomiting  is  caused  by  the  breast  milk,  the  breast  may 
be  abruptly  stopped.  In  the  same  way,  if  there  is  evidence 
that  severe  intestinal  indigestion  is  caused  by  the  breast 
milk,  the  same  holds  true.  We  must  remember,  though,  that 
underfeeding  may  also  cause  loose,  watery,  green,  or  mucous 
stools,  in  which  case  complementing  the  breast  with  a  proper 
bottle  feeding  will  bring  about  normal  stools,  and  the  breast 
feedings  need  not  be  discontinued.  We  should  also  assure 
ourselves  that  the  vomiting  is  not  due  to  some  organic  dis- 
ease such  as  pyloric  stenosis,  in  which  case  the  condition  is 
aggravated  by  a  discontinuance  of  the  breast  feedings. 

CASE  LXI 

(Illustrating  severe  vomiting  caused  by  breast  milk,  and  eventually  remedied 
by  stopping  the  breast  feedings) 

October  26:     Age,  3  months  1  week.     Birth  weight,  5  Ib.  8  oz. 

Present  weight,  10  Ib. 
Gain  since  birth,  4  Ib.  8  oz. 

General  Condition. — Fairly  well  nourished,  well  developed. 

Stools. — Constipated,  one  each  day  with  enema. 

Vomiting. — Excessive,  "  the  larger  part  of  the  food  taken  after  almost  every 
nursing  " ;  continues  right  up  to  time  of  next  feeding. 

Sleep. — Good  during  the  day,  poor  at  night. 

Appetite. — Good;  nurses  ten  to  fifteen  minutes. 

Temperature,  98.6°  F. 

Chief  Complaint. — Vomiting,  constipation. 

Previous  Food. — Exclusively  breast-fed  once  in  two  or  three  hours  and  two  or 
three  times  in  the  night,  making  in  all  eight  or  nine  feedings  in  twenty- 
four  hours.  The  mother  eats  three  hearty  meals  a  day  and  drinks,  besides, 
two  quarts  of  milk.  Her  appetite  is  fair  ( she  forces  herself  to  eat)  and  she 
is  constipated,  requiring  an  enema  each  day. 

Treatment. —  (For  the  mother)  Stop  milk  between  meals;  take  instead  malted 
milk  if  hungry.  Eat  plenty  of  fruit  and  vegetables  for  the  constipation. 
Nux  vomica  and  gentian  prescribed.  (For  the  infant)  Nurse  every  three 
hours,  at  6,  9,  12  A.M.  and  3,  6,  9  P.M.,  six  feedings  in  twenty-four  hours. 
Nurse  for  five  minutes  only  until  after  the  third  day,  when  the  time  may 
gradually  be  increased  to  ten  minutes. 


252 


The  vomiting  was  extreme,  but  was  not  projectile  in  character.  There  waa 
no  visible  peristalsis  of  the  stomach.  The  infant  had  gained  fairly  well  in 
weight.  Its  stools  were  large,  showing  that  a  good  deal  of  food  passed  through 
the  pylorus,  and  it  waa  therefore  concluded  that  there  was  no  pyloric  stenosis 
or  even  pyloric  spasm. 

November  2  (7  days  later)  :     Weight,  10  Ib. 

No  gain,  no  loss. 
General  Condition. — The  same. 
Stools. — Still  somewhat  constipated. 
Vomiting. — Not  at  all  improved. 
A  ppetite. — Hungry. 
Sleep. — Poor. 

Treatment. — Nurse  at  breast  for  five  minutes  every  three  hours  as  above, 
completing  each  feeding  with  three  (gradually  increased  to  four)  ounces 
of  the  following  formula: 

Milk 6  oz.  )  . 

no         I  boiled  and  divided  into  six  portions. 
Water 12  oz.  j 

Sugar 0 

Each  day  increase  the  milk  one  ounce,  allowing  the  quantity  of  water  to 
remain  stationary. 

November  9    (7  days  later)  :     Weight,  10  Ib.  4  oz. 

Gain,  4  oz. 

General  Condition. — The  same. 
Stools. — One  constipated  with  enema. 
Vomiting. — Still  excessive. 
Appetite. — Ravenous. 
Sleep. — Poor. 

Treatment. — Food  prescribed: 

Milk 12  oz.  |  .  Divide  into  six  bottles  of  four  ounces 

Water 12  oz.  j  each.    Feed  after  each  ten-minute 

Sugar.. 0  feeding  at  the  breast  at  6,  9,  12 

A.M.,  3,  6,  9  P.M.,  and  2  A.M. 
November  16  (7  days  later)  :     Weight,  10  Ib.  6  oz. 

Gain,  2  oz. 

General  Condition. — The  same. 
Stools. — One  or  two  normal. 
Vomiting. — Worse  than  at  last  visit. 
Appetite. — Very  hungry. 
Sleep. — Poor. 

The  gain  in  weight  was  unsatisfactory,  and,  as  there  was  no  improvement  in 
the  vomiting,  it  was  decided  to  stop  the  breast  milk,  which  was  considered  the 
cause  of  the  disturbance. 


CONTRA-INDICATIONS  :  BREAST  FEEDING    253 

Treatment.  —  Discontinue  the  breast  milk  and  give 


Milk  ...........    18  oz.  }  1.1..J       Divide  into  six  feedings.    Feed  six 

Water  ..........   18  oz.  J  ounces  at  6,  9,  12  A.M.,  3,  6,  9 

Dextri-maltose.  .  .         oz.  P.M. 


(Increase  a  teaspoonful  at  a  time  to  1  oz.) 

November  23  (7  days  later)  :     Weight,  10  Ib.  11  oz. 

Gain,  5  oz. 

General  Condition.  —  The  same. 
Stools.  —  One  or  two  normal. 

Vomiting.  —  Greatly  improved;  regurgitate*  only  a  mouthful  now  and  then, 
A  ppetite.  —  Hungry. 
Sleep.  —  Improved. 

As  soon  as  the  milk  and  sugar  were  increased  to  a  quantity  sufficient  to 
fulfil  the  infant's  caloric  requirements,  a  steady  and  progressive  gain  in 
weight  was  made  without  any  return  of  the  vomiting,  showing  that  the  vomit- 
ing was  due  to  the  breast  milk. 

Two  Previous  Unsuccessful  Attempts  to  Nurse.  —  Where  a 
mother,  during  her  previous  pregnancies,  has  had  careful 
supervision  and  intelligent  care,  and  every  effort  has  failed 
to  increase  the  supply  of  breast  milk  after  the  births  of 
two  previous  infants,  there  is  almost  sure  to  be  no  milk 
for  the  third  infant.  It  has  been  the  author's  observation 
that  the  milk  is-  far  more  apt  to  diminish  in  quantity  with 
each  succeeding  birth  than  it  is  to  increase,  and  he  con- 
siders it  unwise,  therefore,  to  weaken  the  infant  with  a  vain 
attempt  to  supply  it  with  breast  milk  when  the  chances  of 
success  are  so  slight.  New-born  infants  are  usually  easier  to 
feed  from  the  bottle  than  older  infants,  whose  digestive 
power  has  been  lessened  by  unsuccessful  feeding. 

Puerperal  Convulsions.  —  It  is  a  disputed  question  whether 
or  not  toxic  bodies  are  secreted  in  the  milk  of  eclamptic 
mothers,  but  it  would  seem  to  be  a  common-sense  view  of  the 
subject  not  to  allow  a  mother  to  nurse  her  infant  after  a 
severe  eclampsia.  There  are  certain  cases  of  eclampsia, 
mild  in  character,  in  which  the  mother's  improvement  is  so 
rapid  after  the  birth  of  the  infant  that  within  a  week's  time 
there  may  be  no  danger  in  putting  it  to  the  breast.  It  is, 
however,  safer  not  to  use  the  breast  milk  for  a  week  at  least, 


254  SIMPLIFIED  INFANT  FEEDING 

and  not  at  all  if  the  mother  has  not  entirely  recovered  by 
that  time. 

Pregnancy. — There  can  be  no  argument  in  favor  of  a 
pregnant  woman  nursing  her  infant.  Nature  never  intended 
one  individual  to  furnish  adequate  nutriment  to  an  infant 
in  the  uterus  and  one  at  the  breast  at  the  same  time.  In 
cases  where  an  attempt  has  been  made  to  do  so,  the  milk 
has  been  found  to  have  greatly  deteriorated  and  nursing 
has  proved  harmful  to  embryo,  mother,  and  infant.  In  some 
parts  of  the  country  there  is  an  idea  among  the  laity  that  the 
breast  milk  of  a  pregnant  woman  contains  poisonous  sub- 
stances which  are^  actually  injurious  to  the  nursing  infant. 
Whether  this  is  so  or  not  has  never  been  definitely  proved, 
but  it  is  possible  that  in  certain  toxaemias  of  pregnancy 
harmful  bodies  may  be  secreted  by  the  breast  and  trans- 
mitted to  the  nursing  infant. 

Acute  Infectious  Diseases. — In  some  of  the  acute  infectious 
diseases  lasting  less  than  a  week  the  infant  may  be  tem- 
porarily taken  away  from  the  breast,  as  explained  in  the  sec- 
tion on  ' '  Temporary  Discontinuation  of  the  Breast, ' '  but  in 
prolonged  and  severe  diseases  of  any  kind  the  breast  should 
be  permanently  discontinued  for  the  welfare  of  both  the 
mother  and  the  infant. 

Tuberculosis  and  Other  Chronic  Diseases. — A  tuberculous 
mother  should  never  be  allowed  to  nurse  her  infant,  not  only 
because  of  the  danger  to  the  infant  by  contact  with  her  and 
through  the  milk  itself,  but  also  because  of  the  extremely 
debilitating  effect  upon  the  mother  and  the  unfavorable 
progress  of  the  disease  when  the  added  burden  of  nursing  an 
infant  is  put  upon  her.  This  applies  to-  any  form  of  tuber- 
culosis. 

Epilepsy,  anaemia,  and  nephritis  are  also  contra- indica- 
tions for  the  same  reasons. 

Congenital  syphilis  is  not  a  contra-indication  for  breast 
feeding.  It  is  now  a  well-known  fact  that  there  is  no  such 


CONTRA-INDICATIONS :  BREAST  FEEDING    255 

thing  as  a  non-syphilitic  mother  of  an  infant  with  congenital 
syphilis,  for,  although  the  mother  may  never  have  had  any 
visible  signs  of  syphilis,  she  will,  in  the  majority  of  in- 
stances, show  a  positive  Wassennann  reaction.  The  danger, 
therefore,  of  the  infant's  infecting  the  mother  is  eliminated 
and  the  infant's  chances  of  recovery  are  greatly  advanced 
by  the  breast  feeding,  and,  except  in  very  severe  cases  of 
congenital  syphilis,  we  are  usually  able  to  make  a  favorable 
prognosis  as  to  life  when  the  breast  milk  supply  is  abundant. 
Syphilis  acquired  either  in  the  mother  or  the  infant  after 
birth  is,  however,  a  strong  contra-indication  to  breast  feed- 
ing in  order  that  the  one  may  not  infect  the  other. 

CONDITIONS  UNDER  WHICH  THE  BREAST  SHOULD  BE  TEMPO- 
RARILY DISCONTINUED 

1.  During  an  acute,  though  perhaps  brief,  illness  of  the 
mother. 

2.  In  selected  cases,  during  menstruation. 

3.  In  some  cases  of  acute  diarrhoea  in  the  infant. 

4.  In  some  cases  of  acute  vomiting  in  the  infant. 
During  an  Acute  Illness  of  the  Mother. — During  any  acute 

febrile  disturbance,  where  the  temperature  runs  above  101° 
or  102°,  it  is  well  to  stop  the  breast  temporarily.  It  may  not 
be  possible  at  the  beginning  to  diagnose  the  disease  from 
which  the  mother  is  suffering,  and  it  is  always1  safer  to  stop 
the  breast  milk  for  a  period  of  from  twelve  to  twenty-four 
hours  at  least,  or  until  a  diagnosis  can  be  made.  Influenza, 
pneumonia  of  short  duration,  severe  bronchitis,  mild  cases 
of  diphtheria,  severe  acute  gastro-intestinal  disturbances, 
acute  alcoholism,  acute  laryngitis,  pharyngitis  or  tonsillitis, 
appendicitis,  gall-stones,  sore  breasts  accompanied  by  fever 
not  resulting  in  an  abscess,  or  any  operative  condition  where 
a  rapid  recovery  may  be  expected  after  the  operation,  are 
among  the  acute  diseases  calling  for  a  temporary  discon- 
tinuation of  the  breast. 


256  SIMPLIFIED  INFANT  FEEDING 

If  the  breast  is  to  be  discontinued  for  only  a  period  of 
from  twelve  to  twenty-four  hours,  unsweetened  water  only 
may  be  used  in  the  bottle  for  new-born  infants.  Older  in- 
fants, those  over  four  or  five  months  of  age,  who  have  for- 
merly done  well  on  the  breast  and  are  in  good  general  con- 
dition, may  have  barley  gruel  during  this  short  period.  If  it 
is  necessary  to  discontinue  the  breast  for  more  than  twenty- 
four  hours,  weak  dilutions  of  cow's  milk  without  sugar  are 
advisable,  one-third  milk  and  two-thirds  water  to  begin  with, 
gradually  increasing  this  to  half  milk  and  half  water,  if  the 
infant  seems  hungry  and  has  stood  the  weaker  food  well. 

CASE  LXII 

(Illustrating  temporary  discontinuation  of  the  breast  milk  on  account  of 
operation  upon  mother) 

November  29:     Age,  6  months.     Birth  weight,  7  Ib. 

Present  weight,  17  Ib. 
Gain  since  birth,  10  Ib. 

General  Condition. — Fat;  normal  in  every  way. 
Stools. — One  or  two  normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 
Temperature,  98.6°  F. 

Chief  Complaint. — Mother  has  gall-stones.    Operation  was  advised  by  the  sur- 
geon, since  she  was  suffering  incessantly. 
Previous  Food. — Breast-fed  exclusively  once  in  three  hours,  six  feedings  in 

twenty-four  hours. 

Treatment. —  (For  mother)     Operation  for  gall-stones.      (For  infant)     Stop 
breast  feedings  for  three  days,  giving 

Milk 14  oz.  )  t-M-j       Divide  into  six  feedings.    Feed  7 

Water 28  oz.  j  ounces  every  three  hours,  at  6. 

Sugar 0  9,   12   A.M.,   3,   fi,  9   P.M.,   and 

2  A.M. 

December  2   (3  days  later):     Weight,  17  Ib. 
General  Condition. — Unchanged.  No  loss,  no  gain. 

Stools. — One  or  two  constipated. 
Vomiting. — None. 
A  ppetite. — Hungry. 
Sleep. — Good. 


CONTRA-INDICATIONS:  BREAST  FEEDING    257 

Treatment. — The  mother  now  having  recovered  from  her  anaesthetic  and  the 
immediate  effects  of  the  operation,  the  infant  was  returned  to  the  breast 
and  nursed  every  three  hours. 

Menstruation. — Menstruation  is  not  ordinarily  a  contra- 
indication for  breast  feeding.  Many  nursing  infants  are  not 
affected  in  any  way  during  the  menstrual  period.  Others 
have  colic,  indigestion,  vomiting,  diarrhoea,  or  may  stop 
gaining  in  weight  during  the  week  the  mother  is  flowing, 
but  progress  normally  between  the  periods.  In  some  cases 
the  breast  milk  deteriorates  and  it  becomes  evident  that  the 
infant  cannot  be  kept  upon  the  breast  any  longer.  This  is 
indicated  by  a  permanent  cessation  of  gain  in  weight  or  a 
loss  in  weight,  and  also  by  digestive  disturbances. 


17 


CHAPTER  XX 

BREAST  WEANING  (8  TO  12  MONTHS  OF  AGE) 

IT  is  never  advisable  to  rely  upon  breast  milk  after  the 
twelfth  month,  and  it  is  usually  necessary  to  stop  the  breast 
altogether  at  that  age.  One  hears  of  mothers  who  have 
nursed  their,  infants  successfully  for  eighteen  months,  but 
the  author  has  never  seen  such  a  case  himself.  On  the  other 
hand,  he  has  seen  many  instances  of  bad  malnutrition, 
anaemia,  and  rickets  caused  by  the  giving  of  the  breast 
during  the  whole  or  a  part  of  the  second  year. 

An  infant  should  never  be  weaned  entirely  from  the 
breast  before  the  end  of  the  first  year  except  for  the  failure 
of  the  milk  supply  or  illness  of  the  mother.  Breast  milk  is 
the  best  food  for  any  infant  throughout  the  first  year,  pro- 
vided the  quality  and  quantity  of  the  milk  remains  good  for 
that  length  of  time.  A  large  majority  of  women,  particu- 
larly in  the  larger  cities,  do  not  have  enough  milk  for  their 
infants  after  the  seventh  or  eighth  month.  Everything 
should  be  done  to  keep  up  the  milk  supply  until  at  least  the 
eighth  month,  because  at  that  time  the  infant  may  be  weaned 
without  the  aid  of  the  bottle.  On  the  other  hand,  we  should 
not  persist  in  exclusive  breast  feeding  if  the  infant  does 
not  gain  at  least  three  or  four  ounces  a  week  during  the 
second  half-year.  If  the  infant  is  able  to  get  the  breast  milk 
for  the  first  two  or  three  months  only,  it  is  a  great  advan- 
tage over  bottle  feeding  during  this  period,  and  bottle  feed- 
ings are  much  more  easily  and  successfully  instituted  after 
a  good  start  upon  the  breast. 

The  weaning  process  should  always  be  gradual,  with  the 
exception  of  instances  where  breast  feeding  is  definitely 
contra-indicated,  as  discussed  in  the  chapter  on  that  sub- 

258 


DIARRHCEA  IN  THE  BREAST  FED  259 

ject.  At  first  only  one  artificial  feeding  a  day  should  be 
given  unless  the  breast  milk  is  extremely  deficient  in  quality 
or  quantity.  After  a  week  or  so  a  second  feeding  may  be 
given,  and  each  week  another  artificial  feeding  added  until 
the  infant  is  weaned. 

At  eight  months  of  age,  and  occasionally,  with  large, 
healthy  infants,  at  seven  months,  feedings  should  be  given 
from  a  cup  and  spoon  if  the  breast  milk  has  become  deficient. 
At  nine  months  of  age,  even  in  cases  where  the  infant  is 
doing  extremely  well  upon  the  breast  and  gaining  progress- 
ively in  weight,  it  is  well  to  begin  the  weaning  with  one 
artificial  feeding  a  day.  In  this  way  an  infant  will  learn 
to  eat  from  the  cup  and  spoon  and  become  accustomed  to 
foods  other  than  breast  milk,  so  that  it  can  be  easily  and 
quickly  weaned  at  a  year  of  age  without  the  aid  of  the  bottle. 

There  are  several  reasons  for  weaning  a  baby  without 
the  aid  of  the  bottle.  The  first  and  most  important  one  per- 
haps is  that  bottles  are  difficult  to  keep  clean  and  to  handle, 
and  there  is  always  a  certain  amount  of  danger  from  infec- 
tious diarrhoeas  where  bottle  feedings  are  given.  Another 
reason  is  that  later  the  infant  will  have  to  be  again  weaned 
from  the  bottle,  and  it  is  much  easier  to  do  this  weaning 
at  eight  or  nine  months,  than  it  is  at  fifteen  or  eighteen 
months.  The  food  from  the  cup  and  spoon  may  be  varied 
and  the  infant  early  made  to  like  new  articles  of  diet  and 
acquire  a  taste  for  food  in  general.  It  is  occasionally  most 
difficult  to  teach  infants  to  eat  if  they  have  been  bottle  fed 
up  to  sixteen  or  eighteen  months  of  age. 

CASE  LXIII 

(Showing  an.  infant  of  fifteen  months  who  refused  solid  food  because  it  was 
weaned  from  the  breast  to  the  bottle  at  ten  months  of  age) 
August  18:     Age,  15  months.     Birth  weight,  6  Ib.  8  oz. 

Present  weight,  20  Ib.  14  oz. 
Gain  since  birth,  14  Ib.  6  oz. 

General  Condition. — Fat,  somewhat  anaemic,  rhachitic. 
Stools. — One  normal  per  day. 


260  SIMPLIFIED  INFANT  FEEDING 

Vomiting. — None. 

Appetite. — Will  feed  only  from  bottle,  refusing  all  food  from  the  cup  and  spoon. 
Sleep. — Good. 
Temperature,  98.6°  F. 

Chief  Complaint. — Refusal  to  take  solid  food. 

Previou^  Food. — Had  been  breast-fed  for  the  first  ten  months,  when  an  unfor- 
tunate change  to  bottle  feedings  had  been  made.  Two  weeks  ago  was 
ordered  to  take  potatoes,  spinach,  carrots,  cereals,  and  bread  besides  milk. 
As  the  infant  refused  to  take  food  from  the  cup  and  spoon,  the  mother  had 
given  this  mixture  of  vegetables  and  milk  from  the  bottle,  adding  milk 
enough  to  make  it  run  through  the  nipple.  Given  in  this  extraordinary 
mixture,  the  object  of  the  diet  was  thwarted. 

Treatment. — Stop  all  bottla  feedings  at  once  and  give  solid  food  as  directed, 
allowing  milk  in  the  cup  only. 

It  was  about  four  days  before  any  appreciable  amount  of  food  was  taken, 
but  at  the  end  of  this  period  of  starvation  the  infant  was  hungry  enough  to 
take  any  food  offered.  The  unfortunate  element  of  the  case  was  that  the  infant 
had  been  weaned  from  the  breast  to  the  bottle  at  ten  months  instead  of  con- 
tinuing the  breast  (partially)  until  a  more  gradual  change  to  solid  foods  might 
be  accomplished. 

The  Food  to  Give  When  Weaning. — When  weaning  an  in- 
fant it  is  not  necessary  at  nine  months  of  age  or  with  a  large 
infant  of  seven  or  eight  months  to  modify  the  milk  in  any 
way  or  to  give  complicated  feedings  of  any  sort,  provided 
a  month  or  so  is  taken  in  the  weaning.  If  the  infant  is  being 
nursed  regularly  once  in  four  hours  from  6  A.M.  to  10  P.M., 
with  no  night  feeding,  one  breast  feeding  may  be  omitted  and 
a  well-cooked  cereal  with  milk  and  a  cup  of  undiluted,  un- 
sweetened milk  may  be  substituted  for  the  10  A.M.  nursing. 
The  cereal  should  be  cooked  as  thick  as  for  an  adult,  the 
finer  cereals  being  cooked  at  least  one  hour  and  the  coarser 
ones  at  least  three  hours.  These  cereals  should  be  varied 
from  day  to  day  with  cream  of  wheat,  farina,  wheatina,  oat- 
meal, hominy,  rice,  Ralston 's  food,  and  cornmeal  mush.  The 
variety. teaches  the  child  to  like  different  kinds  of  food,  and 
the  infant  does  not  become  accustomed  to  one  food  and 
refuse  to  take  any  other.  The  coarser  cereals  should  be 
used  where  there  is  any  tendency  to  constipation.  After 
the  infant  has  become  accustomed  to  this  meal  another  meal 


DIABRHCEA  IN  THE  BEEAST  FED  261 

of  the  same  food  may  be  given  at  2  P.M.  in  place  of  the  nurs- 
ing. Later  on  the  third  meal  may  be  substituted  for  the  6  P.M. 
breast  feeding.  At  this  time  the  infant  is  getting  two  feed- 
ings from  the  breast  and  three  feedings  from  the  cup  and 
spoon.  Finally,  the  breast  may  be  omitted  altogether  and 
the  infant  put  upon  a  four-hour  schedule  as  follows : 
6  A.M. — Cereal,  milk,  toast,  or  zwieback. 

10  A.M. — Eight  ounces  of  undiluted  milk  from  the  cup, 
crackers,  toast,  zwieback,  stale  bread. 

2  P.M. — Milk  from  the  cup  and  a  cereal  with  milk.  If  the 
baby  is  one  year  old,  a  baked  potato  with  butter  may  be  given 
at  this  meal  in  place  of  the  cereal,  and  a  little  later  a  puree 
of  spinach,  carrots,  or  green  peas.  After  fourteen  months 
of  age  an  egg  may  be  given. 

6  P.M. — Eight  ounces  of  undiluted  milk  from  the  cup, 
crackers,  stale  bread,  zwieback,  toast. 

10  P.M. — Eight  ounces  of  undiluted  milk  from  the  cup. 
The  intervals  at  which  these  changes  are  made  depend 
upon  the  quality  and  quantity  of  the  breast  milk,  and  the 
general  condition  and  age  of  the  child. 

Under  a  year  of  age  the  weaning  should  be  done  more 
slowly,  provided  the  breast  milk  is  of  good  quality  and  there 
is  no  urgent  reason  for  stopping  its  use.  An  infant  of  eight 
months,  for  instance,  might  have  the  artificial  feedings  sub- 
stituted for  the  breast  feedings  one  at  a  time  at  intervals 
of  two  or  three  weeks,  not  attempting  to  discontinue  the 
breast  feedings  entirely  until  one  year  of  age. 

CASE  LXIV 

(Illustrating  the  correct  method  of  weaning  an  infant  of  eight  months  of  age 
or  older) 

February  28:     Age,  8  months.     Birth  weight,  7  Ib.  12  oz. 

Present  weight,  17  Ib.  3  oz. 
Gain  since  birth,  9  Ib.  7  oz. 
General  Condition. — Somewhat  small,  but  exceedingly  well  nourished;   color 

excellent. 
Stools. — One  normal  each  day. 


262 

Vomiting. — None. 

Appetite. — Takes  breast  well. 

Temperature,  98.6°  F. 

Chief  Complaint. — Inability  of  wet  nurse  to  supply  sufficient  breast  milk. 

Previous  Food. — Breast-fed  exclusively  by  wet  nurse  once  in  three  hours,  six 

feedings  in  twenty-four  hours.    Nurse's  milk  seems  to  have  been  failing 

lately. 
Treatment. — Breast  at  6  A.M.,  2,  6,  10  P.M.;  the  10  A.M.  feeding  to  consist  of 

barley  gruel,  3  ounces,  and  milk,  3  ounces;  fed  with  a  spoon. 

March  6   (6  days  later) :     Weight,  the  same. 

General  Condition. — As  above. 

Stools. — Normal. 

Vomiting. — None. 

Appetite. — Takes  feeding  well  from  cup  and  spoon. 

Sleep. — Good. 

Treatment* — Breast  at  6  A.M.  and  6  and  10  P.M.  At  10  A.M.  and  2  P.M.  give 
a  feeding  of  cereal  with  milk  upon  it  and  a  drink  of  undiluted  milk  from 
the  cup,  using  at  least  six  ounces  of  milk  at  each  feeding. 

March  13  (7  days  later) :     Weight,  17  Ib.  6  oz. 

Gain,  3  oz. 

General  Condition. — As  above. 
Stools. — Normal. 
Vomiting. — None. 

Appetite. — Continues  to  take  food  well. 
Sleep. — Good. 
Treatment. — Give  breast  feedings  at  6  A.M.  and  10  P.M.    At  10  A.M.  and  2  and 

6  P.M.  give  cereal  with  milk  and  a  drink  of  milk  as  above,  adding  a  piece 

of  zwieback  in  the  hand. 

March  23    (10  days  later):     Weight,   18  Ib.  2  oz. 

Gain,  12  oz. 

General  Condition. — Excellent. 
Stools. — Normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 
Treatment. — Breast  at  6  A.M.    Cereal  and  milk  at  10  A.M.  and  2,  6  and  10  P.M. 

March   30    (7   days  later) :     Weight,  18  Ib.  11  oz. 

Gain,  9  oz. 

General  Condition. — As  above. 
Stools. — Slightly  constipated. 
Vomiting. — None. 
A  ppetite. — Excellent. 
Sleep. — Good. 


DIARRHCEA  IN  THE  BREAST  FED  263 

Treatment. — Food  prescribed : 

6  A.M. — Eight  ounces  milk  with  graham  or  oatmeal  crackers. 
10  A.M. — Six  ounces  milk,  four  ounces  cereal. 

2  P.M. — Six  ounces  milk,  four  ounces  cereal,  zwieback. 

6  P.M. — Six  ounces  milk,  four  ounces  cereal. 
10  P.M. — Eight  ounces  milk. 

Urgent  Need  of  Breast  During  an  Acute  Illness  of  the 
Infant. — It  is  a  great  mistake  to  wean  an  infant  because  it  is 
suffering  from  some  acute  intercurrent  affection.  There  is 
no  time  when  an  infant  needs  breast  milk  more  than  during 
an  acute  illness  (other  than  gastro-intestinal)  or  after  any 
operative  procedure,  and  many  disastrous  results  in  the 
treatment  of  these  cases  may  be  directly  traced  to  the  fact 
that  the  infant  was  taken  away  from  the  breast  at  this  time. 
The  feedings  should  be  shortened  and  given  not  oftener 
than  once  in  three  hours,  with  plenty  of  water  between  feed- 
ings to  quench  the  thirst. 

The  Treatment  of  the  Breasts  in  Weaning. — Usually  when 
an  infant  has  been  weaned  from  the  breast  gradually  the 
breast  milk  has  gradually  disappeared,  so  that  by  the  time 
the  infant  is  wholly  weaned  there  is  no  milk  left.  Where 
the  breasts  are  uncomfortable,  a  mother  should  be  instructed 
to  take  a  sufficient  quantity  of  Epsom  salts  to  give  her  six 
or  eight  loose,  watery  movements  a  day,  to  restrict  her  liquid 
food  to  the  extent  of  not  entirely  quenching  her  thirst.  She 
should  also  be  advised  against  the  frequent  use  of  a  breast- 
pump,  for  the  more  frequently  the  breasts  are  pumped  out 
the  longer  it  will  take  to  dry  them  up. 


CHAPTER  XXI 

DIARRHOEA,  VOMITING,  AND  CONSTIPATION 
IN  BREAST-FED  INFANTS 

DlAKRHCEA  IN  BBBAST-FED  INFANTS 

DIAKBHCEA  in  breast-fed  infants  is  not  usually  as  serious 
nor  as  hard  to  control  as  that  found  among  bottle-fed  infants. 
Even  the  normal  stools  of  a  breast-fed  infant  are  usually 
more  watery  than  those  of  a  bottle-fed  infant,  and  are  also 
apt  to  be  more  numerous.  A  breast-fed  baby  will  usually 
have  from  three  to  four  stools  a  day.  The  stools  are  brighter 
in  color,  being  of  an  intense  yellow,  shading  almost  to 
orange.  Minute  flakes  resembling  small  curds  may  be  pres- 
ent throughout  the  stools  of  an  infant  that  is  being  overfed, 
and  are  seen  also  in  the  stools  of  an  infant  that  is  progressing 
normally.  Diarrhoea  is  not  always  a  centra-indication  for 
breast  feeding,  even  as  a  temporary  measure. 

Diarrhoea  in  breast-fed  infants  is  usually  due  to  one  of  the 
following  conditions : 

1.  Overfeeding. 

2.  Changes  in  the  breast  milk  through  a  temporary  ill- 
ness of  the  mother,  or  other  causes. 

3.  Acute  intestinal  indigestion  arising  from  supplement- 
ing the  breast  with  other  foods. 

4.  Infectious  diarrhoeas. 

Overfeeding. — Overfeeding  may  occur  in  the  form  of  too 
frequent  feeding  (that  is,  feedings  coming  too  close  to- 
gether), too  many  feedings  in  twenty-four  hours  making 
the  quantity  too  great,  frequent  night  feedings,  too  long 
a  feeding,  or  milk  that  is  too  rich,  due  to  overfeeding  the 
mother.  The  infant  that  is  being  overfed  may  gain  in  weight 
progressively  and  still  have  frequent  loose  stools,  green  in 
color  and  perhaps  sour-smelling  and  containing  mucus. 
Many  infants  are  fed  whenever  they  cry,  and  the  more  they 

264 


DIAEEHCEA  IN  THE  BREAST-FED  265 

are  fed  the  more  intestinal  indigestion  they  have  and  the 
more  they  cry.  The  fretful,  teething  infant  or  one  having 
a  little  indigestion  is  fed  three  or  four  times  during  the  night, 
or  even  taken  into  bed  with  the  mother  and  allowed  to  suckle 
the  greater  part  of  the  night.  The  result  is  overfeeding 
and  consequent  numerous  loose  stools,  instances  of  which, 
with  treatment,  are  given  in  detail  in  Case  LI.  Over-fed 
infants  who  are  gaining  rapidly  in  weight  and  who  have 
frequent  loose  stools  should  be  fed  once  in  four  hours  at 
6,  10  A.M.,  2,  6,  10  P.M. 

Allow  an  infant  to  nurse  until  it  goes  to  sleep,  or  stops 
voluntarily,  with  the  maximum  time  limit  of  20  minutes. 

If,  as  is  occasionally  the  case,  the  bowels  persist  in  being 
somewhat  loose,  even  to  the  extent  of  six  or  seven  loose  stools 
a  day,  after  everything  has  been  carefully  regulated,  the 
breast  should  still  be  continued  provided  the  infant  is  gam- 
ing well  in  weight  and  is  in  good  general  condition. 

CASE  LXV 

(Illustrating  persistent  diarrhoea  in  an  infant  progressing  normally  otherwise) 
December  20:     Age,  3  weeks.     Birth  weight,  7  Ib.  8  oz. 

Present  weight,  8  Ib.  6  oz. 
Gain  since  birth,  14  oz. 
General  Condition. — Fat,  normal  infant. 
Stools. — Since  the  first  week  of  life,  seven  to  nine  green,  watery,  sour-smelling 

stools  a  day,  with  mucus  and  fine,  flocculent  curds. 
Appetite. — Good;  nurses  fifteen  to  twenty  minutes. 
Vomiting. — None. 
Sleep. — Good. 
Temperature,  98.6°  F. 
Chief  Complaint. — Diarrhoea. 
Previous  Food. — Exclusively  breast-fed  once  in  three  hours,  seven  feedings  in 

twenty-four  hours.    Nurses  until  satisfied,  only  fifteen  or  twenty  minutes, 

never  more.  Mother's  diet  excellent,  her  appetite  good,  her  bowels  normal. 
Treatment. —  (For  the  mother)  Stop  eating  the  coarser  vegetables  and  some 

of  the  fruits  and  omit  milk  between  meals.     ( For  the  infant )     Nurse  every 

four  hours,  at  6,  10  A.M.,  2,  6,  10  P.M.  and  2  A.M. 

The  infant  was  under  observation  throughout  the  first  year.  The  stools 
did  not  improve  in  spite  of  any  changes  in  the  mother's  diet,  nursing  times  or 
intervals,  although  there  was  a  normal  gain  in  tceight  and  the  infant  seemed 
well  in  every  way  except  for  the  numerous  loose  stools. 


266  SIMPLIFIED  INFANT  FEEDING 

On  April  9,  when  it  was  five  months  old,  it  weighed  14  pounds  4  ounces. 
Its  bony  development  was  perfect,  showing  no  rickets ;  its  musculature  was  good, 
and  it  was  a  normal  infant  in  every  way.  After  this  date  the  bowels  began 
to  improve  gradually,  and  finally  became  normal,  the  infant  still  being  ex- 
clusively breast-fed. 

Changes  in  the  Breast  Milk  from  Temporary  Illness  of  the 
Mother  or  Other  Causes. — Elaborate  treatment  for  acute  diar- 
rhoeas of  breast-fed  infants  when  due  to  temporary  changes 
in  the  breast  milk  is  uncalled  for  and  is  apt  to  work  harm. 
The  author  has  found  that  if  an  infant  is  nursed  regularly 
upon  the  breast  the  diarrhoea  will  quickly  right  itself  with- 
out further  treatment,  undoubtedly  because  the  changes  in 
the  milk  are  temporary.  Such  a  diarrhoea  may  be  caused 
by  almost  any  acute  illness  of  the  mother,  and,  on  the 
other  hand,  may  also  occur  without  the  mother's  appar- 
ently being  sick.  There  is  always  the  possibility  that  some 
food  the  mother  has  eaten  has  affected  the  infant,  though 
seemingly  having  had  very  little  effect  upon  herself.  What 
the  changes  are  that  take  place  in  the  breast  milk  it  is  not 
often  possible  to  tell,  for  we  know  very  little  about  breast 
milk  except  its  actual  content  of  fat,  sugar,  protein,  salts, 
and  water.  It  has  been  asserted  that  the  percentage  of 
protein  increases  and  that  the  fats  diminish  temporarily 
during  such  a  disturbance,  but  it  is  doubtful  if  this  explains 
entirely  the  cause  of  diarrhoea.  It  is  advisable  to  give  the  in- 
fant plain,  unsweetened  water,  discontinuing  the  breast  milk 
for  twelve  hours  after  the  onset  of  any  form  of  diarrhoea. 

It  is  a  well-known  fact  that  any  nervous  strain,  such  as 
a  fright,  a  quarrel,  a  misfortune,  a  sorrow,  or  worry  about 
the  infant,  will  cause  changes  in  the  breast  milk  which  will 
bring  about  digestive  disturbances  in  the  infant.  These 
disturbances  usually  disappear  so  soon  as  the  source  of  the 
trouble  is  removed. 


DIAEEHCEA  IN  THE  BEEAST-FED  267 

CASK  LXVI 

(Illustrating  acute  diarrhoea  in  the  breast-fed  infant  and  its  treatment) 
October  28 :     Age,  4  months  3  weeks.     Birth  weight,  8  Ib.  8  oz. 

Present  weight,  15  Ib. 
Gain  since  birth,  6  Ib.  8  oz. 
General  Condition. — Large,  fat,  normal  infant. 

Stools. — For  two  days  eight  to  ten  green f  tvatery  stools  with  normal  fecal  odor, 
much  mucus  and  fine  curds,  no  blood.  Had  formerly  had  one  or  two  normal 
movements  a  day. 

Vomiting. — Some  at  the  onset  of  the  diarrhoea ;  none  now. 
Appetite. — Seems  hungry. 
Temperature,  98.6°  F. 
Sleep. — Poor. 

Chief  Complaint. — Diarrhoea. 

Previous  Food. — Breast-fed  exclusively  every  three  hours,  six  feedings  in 
twenty-four  hours. 

At  the  onset  of  the  diarrhoea  there  was  vomiting,  and  for  twelve  hours 
nothing  but  water  was  given  until  the  vomiting  stopped.    The  mother  declared 
that  no  food  other  than  breast  milk  had  been  given  to  cause  diarrhoea. 
Treatment. — The  breast  to  be  continued  at  the  same  intervals,  nursing  only  for 
ten  minutes. 

November  2  (5  days  later)  :     Weight,  15  Ib.  2  oz. 

Gain,  2  oz. 

General  Condition. — Unchanged. 
Stools. — One  or  two  normal. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 

Acute  Intestinal  Indigestion  from  Other  Food  Than  the 
Breast  Milk. — Without  appearing  to  be  suspicious  of  his 
directions  not  having  been  faithfully  carried  out,  the  phy- 
sician should  take  every  means  to  ascertain  if  the  infant  has 
had  other  food  than  the  breast  which  might  account  for  its 
diarrhoea.  This  will  happen  frequently  without  the  mother's 
knowledge  when  the  infant  is  in  the  care  of  a  nursemaid  or 
other  person.  An  acute  onset  with  diarrhoea,  fever,  and 
vomiting  in  a  breast-fed  infant  is  usually  an  indication  that 
some  food  other  than  the  breast  milk  has  been  given  to  cause 
it.  Where  such  a  condition  prevails,  the  infant  should  be 
given  a  dose  of  castor  oil  and  the  breast  stopped  for  from 


268 

twelve  to  twenty-four  hours,  substituting  unsweetened, 
boiled  water  exclusively  until  the  fever  and  the  acute  symp- 
toms have  subsided.  Where  a  mother  objects  to  this  plan  of 
1 l  starvation,"  the  white  of  an  egg  may  be  given  raw  in  eight 
ounces  of  water  to  pacify  her.  The  breasts  may  be  emptied 
with  the  breast-pump  if  they  become  uncomfortably  full. 

CASE  LXVII 

(Illustrating  diarrhoea  in  breast-fed  infant  from  irrational  food) 
November  1 :     Age,  8  months.     Birth  weight,  unknown. 

Present  weight,  19  Ib. 

General  Condition. — Fat,  normal  infant,  except  for  present  febrile  disturbance. 
Stools. — One  per  day  until  the  present;  since  morning  there  have  been  four 
green,  watery,  foul-smelling  stool*,  with  mucus  and  some  curds,  but  no 
blood. 

Vomiting. — Once  or  twice  at  the  onset. 
Appetite. — Refuses  breast. 
Sleep. — Fretful  all  day. 
Temperature,  102°  F. 

Chief  Complaint. — IMarrhoea  with  sudden  onset. 

Previous  Food. — Breast-fed  exclusively  once  in  three  hours,  six  feedings  in 
twenty-four  hours.  The  nurse  was  suspected  of  giving  food  to  baby  with- 
out mother's  knowledge. 

Treatment. — Give  two  teaspoonfuls  of  castor  oil.  Stop  breast  feeding  and  give 
nothing  but  water  until  next  visit. 

November  2  (next  day)  : 
General  Condition. — Appears  perfectly  well. 
Stools. — Three  large,  loose,  foul-smelling  stools  following  the  castor  oil.     Since 

then  the  bowels  have  not  moved. 
Appetite. — Hungry  this  morning. 
Vomiting. — None. 
Sleep. — Sound  all  night. 
Temperature,  98.6°  F. 
Treatment. — Return  to  breast  feedings  as  before. 

Infectious  Diarrhoeas. — Infectious  diarrhoeas  are  seldom 
seen  in  infants  who  are  exclusively  breast-fed,  but  are  not 
uncommon  in  infants  who  are  partially  breast-fed.  The 
treatment  of  infectious  diarrhoea  in  breast-fed  infants  does 
not  differ  greatly  from  that  of  the  bottle-fed.  If  there  is  a 


VOMITING  IN  THE  BREAST-FED  269 

plentiful  supply  of  breast  milk  and  the  baby  has  been  breast- 
fed exclusively,  there  is  no  reason  why  the  breast  milk  should 
be  permanently  discontinued,  although  a  temporary  discon- 
tinuation for  two  or  even  three  days  may  become  necessary. 
However,  when  there  is  only  a  small  amount  of  breast  milk 
or  it  is  of  doubtful  quality  it  is  generally  advisable  to  dis- 
continue it  altogether. 

VOMITING  IN  BREAST-FED  INFANTS 

Vomiting  in  breast-fed  infants,  as  in  bottle-fed,  is  of  two 
varieties,  acute  and  habitual. 

Acute  Vomiting. — Acute  vomiting  is  the  result  of  an  acute 
indigestion.  Its  treatment  does  not  differ  in  any  way  from 
that  of  bottle-fed  infants.  All  food  and  water  should  be 
temporarily  stopped,  the  bowels  emptied,  and  measures 
recommended  in  the  section  on  ''Vomiting  in  Bottle-fed  In- 
fants ' '  should  be  instituted.  The  breast  may  be  discontinued 
until  the  acute  symptoms  have  subsided  and  the  vomiting 
controlled. 

Habitual  Vomiting. — By  habitual  vomiting  is  meant  vomit- 
ing occurring  after  most  or  all  of  the  feedings  and  which 
has  persisted  for  a  number  of  days  or  weeks.  Its  causes  may 
usually  be  traced  to  one  of  the  following  conditions : 

1.  Errors  in  the  details  of  breast  feeding,  mother's  diet, 
etc. 

2.  Too  rich  milk. 

3.  Organic  causes. 

For  errors  in  the  management  of  breast  feeding,  mother's 
diet,  etc.,  see  Chapter  XVII. 

While  the  baby  is  vomiting  excessively  the  four-hour 
feedings  should  be  tried  or  the  nursings  may  be  shortened 
to  three  or  four  minutes  for  a  day  or  two,  being  gradually 
lengthened  to  five  minutes  at  each  nursing.  The  foremilk 
being  less  rich  in  fat  than  the  milk  which  comes  at  the 
end  of  the  nursing,  the  shortening  of  the  nursing  period 
is  doubly  beneficial,  for  not  only  is  less  food  taken  at  each 


270  SIMPLIFIED  INFANT  FEEDING 

feeding,  but  the  richer  portion  of  the  milk  is  left  in  the 
breasts.  These  short  nursings,  however,  are  never  indicated 
until  every  effort  has  been  made  to  regulate  the  mother's 
diet. 

Some  infants  vomit  a  great  deal  and  at  the  same  time  gain 
progressively  in  weight,  the  vomiting  apparently  doing  them 
no  harm.  On  the  other  hand,  there  are  infants  who  are 
vomiting  comparatively  small  amounts  of  food,  but  who  are 
not  gaining  in  weight  nor  progressing  normally  in  other 
ways.  Infants  of  this  class  need  more  food,  and,  where  the 
breast  milk  cannot  be  improved  by  the  usual  methods,  bottle 
feedings  must  be  instituted.  Mothers  are  apt  to  exaggerate 
the  amount  of  the  vomiting,  and  the  physician  must  take  this 
into  consideration  and  ascertain  for  himself  the  actual 
amount  of  vomiting  before  advising  treatment. 

Milk  flows  much  more  rapidly  from  some  breasts  than  it 
does  from  others.  If  there  is  a  liberal  supply  of  breast  milk 
the  milk  may  flow  so  rapidly  that  considerable  air  is  swal- 
lowed and  vomiting  may  occur  as  a  consequence.  When  it 
has  been  decided  that  vomiting  is  due  to  this  cause  the  con- 
dition may  usually  be  controlled  by  instructing  the  mother 
upon  the  proper  position  in  which  to  nurse  her  infant.  ( For 
organic  causes,  see  page  208.) 

CONSTIPATION  IN  BREAST-FED  INFANTS 

Constipation  in  breast-fed  infants  is  generally  due  to  one 
or  more  of  the  following  causes : 

1.  Irregularity  in  nursing  and  too  frequent  nursings. 

2.  Constipation  of  the  mother. 

3.  Insufficiency  of  breast  milk. 

4.  Excessive  vomiting. 

5.  The  abuse  of  cathartics. 

Irregular  and  Too  Frequent  Feedings. — So  much  has  been 
said  upon  the  subject  of  irregularity  in  feeding  that  it  is 
only  necessary  to  say  here  that  it  is  a  frequent  cause  of  con- 


CONSTIPATION  IN  THE  BREAST-FED         271 

stipation.  Frequent  and  irregular  feeding  sets  up  gastric 
indigestion,  which  may  be  the  cause  of  either  diarrhoea  or 
constipation.  The  condition  is  usually  controlled  when  the 
mother  has  been  directed  to  feed  her  infant  at  stated  times 
(using  the  three-hour  interval)  and  to  stop  all  night  feedings 
after  three  or  four  months  of  age. 

CASE  LXVIII 

(Illustrating  a  case  of  constipation  from  too  frequent  and  irregular  feedings) 
September  14:     Age,   1  month.     Birth  weight,  6  Ib. 

Present  weight,  8  Ib. 
Gain  since  birth,  2  Ib. 
General  Condition. — Well  nourished. 
Stools. — One  yellow  or  green,  occasionally  with  some  mucus,  but  botcels  never 

move  loithout  a  glycerine  suppository  or  an  enema  each  day. 
Vomiting. — A  great  deal  immediately  after  each  feeding. 
Appetite. — Good;  takes  breast  twenty  minutes. 
Sleep. — Poor  and  at  intervals  only;  occasional  crying. 

Previous  Food. — 'Breast-fed  exclusively  once  in  two  or  two  and  a  half  hours  and 
two  or  three  times  in  the  night  and  without  any  regularity.  Mother's  diet 
correct,  her  appetite  good,  and  her  bowels  move  once  a  day  with  the 
occasional  help  of  milk  of  magnesia. 

Treatment. — Infant  to  be  nursed  with  great  regularity  once  in  three  hours, 
at  6,  9,  12  A.M.,  3,  6,  9  P.M.,  and  2  A.M.,  beginning  with  five-minute  feedings, 
and,  as  soon  as  the  colic  has  stopped  and  the  bowels  have  become  normal, 
increasing  the  time  of  feeding  to  ten  minutes. 

September  21   (7  days  later)  : 

When  the  above  schedule  had  been  carried  out,  the  constipation  and  colic 
Mrere  controlled. 

Constipation  of  the  Mother. — In  a  large  percentage  of 
breast-fed  infants  that  are  constipated  but  otherwise  doing 
well  upon  the  breast  it  will  be  found  that  the  mother  herself 
is  constipated.  It  is  impossible  to  overcome  this  condition 
in  the  infant  unless  the  mother's  condition  is  first  corrected. 
The  coarser  articles  of  diet,  particularly  the  coarser  cereals, 
breads,  and  vegetables  and  the  use  of  a  large  amount  of  fruit 
should  be  advised.  ( See ' '  Mother 's  Diet, ' '  page  222. )  Salad 
made  with  a  simple  olive-oil  dressing  may  be  eaten  daily  and 
will  often  act  as  a  laxative.  Any  vegetable  causing  indiges- 


272  SIMPLIFIED  INFANT  FEEDING 

tion  in  the  mother  or  colic  in  the  infant  should  be  prohibited. 
It  is  usually  better  to  give  minute  instructions  about  the 
fruit,  directing  that  four  or  five  apples,  oranges,  pears, 
plums,  or  peaches  shall  be  eaten  during  the  day.  These  may 
be  taken  between  meals,  as  well  as  with  the  meals,  and  eaten 
either  raw  or  cooked.  Even  where  the  mother's  bowels 
move  normally  every  day,  the  infant's  constipation  may  be 
improved  by  instituting  this  change  in  the  mother's  diet. 

When  these  dietetic  measures  fail  it  becomes  necessary  to 
give  the  mother  a  mild  cathartic,  and  fluidextract  of  cascara, 
administered  in  doses  of  fifteen  to  thirty  drops  three  times 
a  day  before  eating,  has  been  found  to  act  best  upon  the 
infant's  bowels. 

CASE  LXIX 

(Illustrating  the  control  of  constipation  in  a  breast-fed  infant  by  treating  the 
constipation  of  the  mother) 

July  9:     Age,   1   month.     Birth  weight,  8  Ib. 
Present  weight,  9  Ib. 
Gain  since  birth,  1  Ib. 

General  Condition. — Well  nourished,  normal  infant. 
Stools. — One  a  day  with  suppository  or  cathartic. 
Vomiting. — None. 

Appetite. — Hungry ;  nurses  fifteen  to  twenty  minutes. 
Sleep. — Good. 
Temperature,  98.6°  F. 
Chief  Complaint. — Constipation. 

Previous  Food. — Breast-fed  exclusively  once  in  three  hours,  seven  feedings  in 
twenty-four  hours.  Mother's  diet  is  correct  and  includes  plenty  of  fruit 
and  vegetables;  she  was  taking  no  milk,  but  her  bowels  were  stubbornly 
constipated. 

Treatment. —  (For  mother)  Fifteen  drops  of  fluidextract  of  cascara  three 
times  a  day  before  eating,  increasing  to  thirty  drops  if  necessary. 

The  infant's  constipation  disappeared  under  this  treatment,  and  its 
bowels  moved  of  their  own  accord  once  or  twice  a  day  thereafter. 

Insufficient  Food. — As  one  might  expect,  an  infant  who  is 
not  getting  enough  nourishment  to  gain  properly  in  weight  is 
very  often  constipated.  There  is  not  enough  food  to  leave 


CONSTIPATION  IN  THE  BREAST-FED        273 

a  sufficient  residue  in  the  bowels  to  cause  an  evacuation  of 
them  each  day.  An  inspection  of  the  infant  for  malnutrition 
and  a  history  of  its  gain  or  loss  in  weight  will  determine 
whether  insufficient  breast  milk  is  causing  the  constipation. 
If  the  mother  has  not  kept  a  record  of  the  infant's  weight 
with  accurate  scales,  the  physician  should  follow  the  weight 
himself  for  at  least  a  week  before  making  his  diagnosis. 
When  it  has  been  decided  that  the  constipation  is  due  to 
insufficient  nourishment,  every  effort  should  be  made  to 
improve  the  breast  milk,,  and,  if  this  is  not  possible,  artificial 
feedings  should  be  added  to  the  breast  supply.  The  consti- 
pation will  usually  disappear  at  once  under  this  treatment. 


CASE  LXX 

(Illustrating  constipation  due  to  insufficient  breast  milk  and  underfeeding  of 
infant) 

May  14:  Age,  5  weeks.  Birth  weight,  5  Ib.  14  oz. 
Present  weight,  5  Ib.  8  oz. 
Loss  since  birth,  6  oz. 

General  Condition. — Poorly  nourished;  fontanel  depressed. 
Stools. — Constipated;   one  small,  yellow  stool  each  day  with  enema,  watery 

in  consistency  and  containing  some  mucus. 
Vomiting. — None. 

Appetite. — Seems  hungry ;  nurses  thirty  to  forty  minutes. 
Sleep. — Cries  a  great  deal,  night  and  day. 
Temperature,  97°  F. 
Chief  Complaint. — Constipation. 
Previous  Food. — Breast-fed  exclusively  every  three  hours  in  the  daytime,  with 

two  or  three  feedings  at  night,  eight  or  nine  feedings  in  twenty-four  hours. 

Mother's  diet  a  very  generous  one,  her  appetite  good,  her  bowels  constipated, 

for  which  she  takes  fluidextract  of  cascara. 
Treatment. — One  breast  for  ten  minutes  every  three  hours,  at  6,  9,  12  A.M.,  3,  6, 

9  P.M.,  and  2  A.M.,  completing  each  nursing  with  from  two  and  a  half  to 

three  and  a  half  ounces  of  the  following  formula : 

'     „       '  }-  boiled  and  divided  into  seven  bottles. 
Water 12  oz. 

Sugar 0 

18 


274  SIMPLIFIED  INFANT  FEEDING 

Each  day  increase  the  milk  and  allow  the  quantity  of  water  to  remain 
constant  until  the  formula  contains: 


Milk  ............  ...........   12  oz.  >  ^j^  and  divided  ag  before. 

Water  .....................   12  oz.  j 

Sugar  ......................     0 

May  22    (8  days  later):     Weight,  6  Ib.  2  oz. 

Gain,  10  oz. 

General  Condition.  —  Somewhat  improved. 
Stools,  —  One  normal  each  day. 
Vomiting.  —  None. 
Sleep.  —  Good. 
Appetite.  —  Satisfied. 

As  the  food  was  gradually  increased  in  strength  and  sugar  added,  the  bowela 
remained  normal  and  a  progressive  gain  in  weight  was  made. 

Excessive  Vomiting.  —  Excessive  vomiting  acts  in  the  same 
way  as  underfeeding  in  causing  constipation.  The  infant 
vomits  so  much  that  there  is  not  enough  food  left  in  the 
bowel  to  cause  a  daily  evacuation.  Excessive  vomiting  is 
necessarily  accompanied  by  malnutrition.  Extreme  in- 
stances of  constipation  caused  by  vomiting  are  seen  in  in- 
fants suffering  with  pylorospasm  or  pyloric  stenosis,  not 
enough  food  going  through  the  pylorus  to  give  a  normal  stool 
each  day.  To  overcome  this  form  of  constipation  the  vomit- 
ing itself  must  be  controlled. 

The  Abuse  of  Cathartics.  —  There  is  no  more  difficult  form 
of  constipation  to  overcome  than  that  due  to  the  habitual 
administration  of  cathartics.  Mothers  frequently  give  their 
infants  castor  oil  or  castoria  because  of  a  slight  tendency 
to  constipation.  This  only  serves  eventually  to  increase  the 
constipation,  and  the  cathartic  has  to  be  repeated.  This 
state  of  affairs  goes  on  for  a  time,  and  then  the  dose,  to  have 
an  effect,  must  be  increased.  The  treatment  indicated  in  this 
case  is  the  same  as  that  recommended  in  the  section  on  *  '  Con- 
stipation in  Bottle-fed  Infants,  '  '  page  170. 


CHAPTER  XXII 

THE  USE  OF  BOILED  MILK  IN  INFANT  FEEDING 

THERE  are  two  distinct  and  entirely  different  reasons  for 
boiling  cow's  milk  during  the  first  year  of  an  infant's  life: 
First,  to  destroy  any  harmful  bacteria  which  the  milk  may 
contain,  and  by  so  doing  to  prevent  disease ;  and,  second,  to 
make  the  milk  more  digestible  and  to  prevent  or  overcome 
any  digestive  disturbances,  provided  boiling  has  this  effect 
upon  the  individual  infant.  In  this -country  the  bacterio- 
logical content  of  milk  has  attracted  so  much  attention  that 
we  have  not  studied  sufficiently  the  difference  in  the  digesti- 
bility of  boiled  and  unboiled  milk,  for  we  must  study  the 
problem  entirely  apart  from  the  bacteriological  side. 

All  pediatricians  are  agreed  that  milk  from  healthy 
tuberculin-tested  cows,  and  with  a  low  bacterial  content,  is 
advisable  for  infant  feeding  purposes.  It  is  the  general 
consensus  of  opinion  in  America  that  good  milk  need  not  be 
boiled,  although  some  authorities  are  of  the  opinion  that  all 
milk  fed  to  infants  should  be  pasteurized.  We  are  also 
agreed  that  when  it  is  impossible  to  procure  good  milk  sick- 
ness can  be  avoided  by  pasteurization  or  boiling,  and  that 
one  or  the  other  is  necessary  when  a  good  milk  supply  is  not 
available.  The  only  question  then,  so  far  as  the  bacteriology 
of  milk  is  concerned,  is  whether  pasteurization  or  boiling  of 
milk  may  be  continued  over  a  prolonged  period  without 
harmful  results. 

Perhaps  an  even  more  important  phase  of  the  question  is 
whether  the  boiling  of  cow's  milk  so  changes  it  that  it  is 
better  borne  by  infants  who  have  a  low  digestive  capacity 
or  who  are  suffering  from  actual  digestive  disturbances. 

Our  problem,  then,  divides  itself  into  several  subheads. 

1.  Does  the  prolonged  use  of  boiled  milk  cause  nutritional 

275 


276  SIMPLIFIED  INFANT  FEEDING 

disorders  such  as  rickets,  anaemia,  malnutrition,  poor  muscu- 
lature, or  scurvy? 

2.  Does  the  change  from  unboiled  to  boiled  milk  cause 
digestive  disturbances  when  fed  to  infants  who  have  no  diffi- 
culty in  digesting  unboiled  milk  I 

3.  Does  the  change  from  boiled  milk  to  unboiled  milk 
ever  cause  digestive  disturbances? 

4.  Does  boiled  milk  aid  us  in  overcoming  digestive  dis- 
turbances such  as  intestinal  indigestion,  with  or  without 
diarrhoea,  or  vomiting? 

5.  Does  boiled  milk  cause  constipation? 

6.  Is  boiled  milk  as  readily  assimilated  as  unboiled  milk, 
or  is  the  nutritional  value  of  milk  lessened  by  boiling? 

There  are  three  ways  of  attacking  these  problems :  First, 
laboratory  experiments;  second,  animal  experiments;  and, 
third,  clinical  observations  upon  babies.  There  has  been  a 
great  deal  of  work  done  and  there  is  a  vast  amount  of  litera- 
ture from  the  first  and  second  viewpoints,  but  very  little  has 
been  written  upon  the  clinical  side  of  the  question.  Labora- 
tory and  animal  experiments  are  very  valuable,  but  the  real 
test  of  any  feeding  problem  is  the  actual  result  obtained  in 
a  series  of  babies  who  are  carefully  observed  over  a  long 
period  of  time.  Most  of  those  who  have  written  upon  this 
subject  have  concluded  that  actual  clinical  observations  were 
necessary  to  determine  the  relative  value  and  usefulness  of 
boiled  and  unboiled  milk  in  infant  feeding.  Some  of  the  ani- 
mal and  test-tube  experiments,  although  interesting  and  in- 
structive, do  not  throw  any  real  light  upon  the  practical 
problem  of  feeding.  For  instance,  whether  calves  do  as  well 
upon  boiled  cow's  milk  as  they  do  upon  unboiled  milk  of 
their  own  species,  and  whether  babies  do  as  well  upon  boiled 
human  milk  as  upon  unboiled  milk  of  their  own  species  can- 
not help  us  to  decide  the  problems  which  are  enumerated 
above.  At  best  the  feeding  of  cow's  milk  to  infants  is  an 


FIG.  14. — Scurvy,  with  swelling  over  tibia  and  femur  of  both  lega. 


BOILED  MILK  IN  INFANT  FEEDING         277 

artificial  procedure,  and  we  must  not  allow  such  analogies 
to  confuse  us. 

In  approaching  the  subject  from  a  clinical  standpoint, 
it  is  necessary  that  the  infants  upon  whom  any  feeding  ex- 
periments are  tried  should  have  good  care  and  the  proper 
hygienic  surroundings  in  order  to  be  under  the  most  favor- 
able and  natural  circumstances.  For  this  reason  it  would  be 
better  not  to  take  institution  infants  nor  those  in  the  lower 
walks  of  life  whose  hygienic  surroundings  are  poor.  The 
following  cases  are  selected  from  private  patients  and  the 
better  class  of  dispensary  patients,  whose  intelligence  can 
be  relied  upon  to  carry  out  the  directions  given. 

Does  the  Prolonged  Use  of  Boiled  Milk  Cause  Nutritional 
Disorders  Such  as  Rickets,  Anaemia,  Malnutrition,  Poor  Muscu- 
lature, or  Scurvy? — First,  we  must  realize  that  in  this  question 
we  are  hampered  by  tradition.  We  have  all  been  taught 
and  have  heard  it  repeated  so  many  times  that  boiled  milk 
is  liable  to  cause  nutritional  disturbances  that  it  is  difficult 
to  put  one's  self  into  an  open-minded  attitude  toward  the 
subject.  Where  this  theory  originated  no  one  seems  to 
know,  but  surely  there  is  no  conclusive  evidence  found  in 
medical  literature  to  prove  that  boiled  milk  does  cause  these 
nutritional  disturbances. 

Morse,  in  a  very  thorough  review  of  the  literature  upon 
the  subject,  says  that  there  is  relatively  little  evidence  on 
either  side,  although  he  quotes  Finkelstein  as  saying  that 
there  was  no  evident  difference  in  the  results  with  raw  and 
cooked  milk  in  reference  to  sixty  well  and  fifty-three  sick 
babies.  Leopold  did  not  find  any  evidence  of  rickets,  anaemia, 
or  malnutrition  in  a  number  of  infants  fed  with  Schloss  milk 
over  a  long  period. 

In  a  very  active  pediatric  practice  and  hospital  experi- 
ence, the  author  has  used  boiled  milk  mixtures  almost  exclu- 
sively for  the  past  eight  years  (at  the  present  writing).  He 
has  fed  many  hundreds  of  infants  of  all  ages  and  conditions 


278  SIMPLIFIED  INFANT  FEEDING 

of  nutrition,  and  has  fed  them  boiled  milk  mixtures  through- 
out the  bottle  period,  in  many  of  them  from  birth.  He  has 
had  the  opportunity  of  observing  hundreds  of  his  private 
cases  throughout  early  childhood.  Nutritional  disturbances 
are  rare  indeed  among  these  patients,  while  formerly  they 
were  far  more  frequently  seen  when  raw  milk  mixtures  were 
used  as  a  routine.  A  more  robust,  rosy  series  of  children 
with  firmer  muscles  and  more  normal  appearing  bones  would 
be  hard  to  find.  The  author  is  therefore  convinced  beyond 
all  question  of  doubt  that  boiled  milk  does  not  cause  rickets, 
malnutrition,  anaemia,  scurvy  or  poor  musculature. 

The  mixtures  used  were  simple  milk  dilutions,  usually 
beginning  with  one-third  milk  and  gradually  increasing  up  to 
one-half  milk,  two-thirds  milk,  or  three-quarters  milk.  The 
carbohydrate  used  was  either  cane  or  malt  sugar  or  malt 
soup  mixtures.  In  boiling  the  milk,  the  milk  and  water  were 
first  mixed  together  and  brought  rapidly  to  a  boil,  stirring 
constantly  so  that  no  scum  formed  upon  the  top,  and  after 
it  had  come  to  the  boiling-point  it  was  allowed  to  boil  actively 
for  three  minutes.  It  was  then  taken  off  the  stove  and  put 
into  the  bottles  for  the  day,  and  rapidly  cooled. 

These  infants  were  carefully  observed  throughout  this 
period,  being  watched  especially  for  evidences  of  rickets  and 
anaemia.  Most  of  them  had  a  certain  degree  of  malnutrition 
when  they  came  under  observation,  and  a  few  of  them  had 
poor  bony  development.  Many  of  them  had  marked  rickets 
at  the  beginning,  which  improved  with  noticeable  rapidity, 
so  that  at  the  end  of  the  bottle  period  the  f  ontanel  was  normal 
in  size,  the  sutures  united,  and  there  were  no  remaining 
evidences  of  it. 

They  did  not  develop  rickets,  but  as  a  whole  showed  a 
marked  improvement  in  nutrition  and  musculature;  and 
developed  into  normal,  healthy  infants.  The  condition  of  the 
skin,  the  hair,  the  color,  the  general  alertness,  and  sense  of 


BOILED  MILK  IN  INFANT  FEEDING         279 

well-being  were  exceptionally  good,  all  of  which  cannot  be 
recorded  in  figures  nor  be  graphically  shown,  as  is  so  easily 
done  with  the  weight  chart. 

Scurvy  did  not  develop  in  any.  In  all  probability  this 
was  because  orange  juice  was  given  daily  throughout  the 
period  of  boiling  the  milk.  If  this  precaution  is  taken  when 
boiled  milk  is  given  over  any  extended  period  of  time  we 
might  eliminate  the  question  of  scurvy.  Since  severe  cases 
of  scurvy  can  be  overcome  in  a  few  days '  time  by  adminis- 
tering orange  juice,  even  though  boiled  milk  is  continued,  it 
would  be  only  logical  to  conclude  that  orange  juice  will  pre- 
vent scurvy.  Undoubtedly  there  is  evidence  in  the  literature 
that  scurvy  is  produced  by  boiled  milk  feedings  when  orange 
juice  is  not  given. 

Does  the  Change  from  Unboiled  to  Boiled  Milk  Cause  Diges- 
tive Disturbances  When  Fed  to  Infants  Who  Have  No  Difficulty 
in  Digesting  Unboiled  Milk? — It  has  been  the  author's  custom 
in  the  last  few  years  to  use  boiled  milk  when  starting  to  feed 
infants  upon  cow 's  milk  for  the  first  time,  and,  although  the 
majority  were  having  digestive  disturbances  or  malnutri- 
tion, a  certain  number  of  cases  were  normal  infants  without 
digestive  trouble.  It  is  occasionally  advisable  to  boil  an  in- 
fant 's  food  for  a  journey  or  when  out  of  town  where  the  milk 
supply  cannot  be  relied  upon.  The  author  has  never  seen 
a  single  instance  where  this  change  from  unboiled  milk  to 
boiled  milk  caused  any  gastric  or  intestinal  indigestion. 
On  the  other  hand,  as  stated  below,  boiled  milk  has  repeat- 
edly been  used  in  infants  who  have  digestive  disturbances, 
with  the  result  that  such  disturbances  were  overcome. 
Whether  this  would  be  true  of  top  milks  with  a  high  per- 
centage of  fat  is  not  known,  as  the  observations  were  en- 
tirely limited  to  the  use  of  simple  dilutions  of  full  milk  or 
occasionally  skimmed  milk.  Formerly,  in  starting  infants 


280  SIMPLIFIED  INFANT  FEEDING 

for  the  first  time  on  cow 's  milk,  it  was  a  frequent  occurrence 
to  see  those  with  a  normal  digestion  get  up  digestive  disturb- 
ances, and  upon  boiling  the  milk  to  have  these  disturbances 
disappear.  As  an  experiment,  the  author  changed  a  group 
of  infants  who  were  doing  well  upon  unboiled  milk  to  boiled 
milk  without  causing  digestive  disturbances.  This  has,  there- 
fore, forced  the  conclusion  that  the  change  from  unboiled 
milk  to  boiled  milk  does  not  cause  indigestion  either  in  the 
form  of  vomiting,  diarrhoea  or  discomfort,  though  this  is 
contrary  to  popular  opinion  in  this  country. 

Does  the  Change  from  Boiled  Milk  to  Unboiled  Milk  Ever 
Cause  Digestive  Disturbances? — Further  evidence  that  boiled 
milk  is  more  digestible  than  unboiled  milk  is  found  in  indi- 
vidual cases  who  have  no  digestive  disturbances  when  given 
boiled  milk  feeding,  perhaps  over  a  prolonged  period,  but 
who  get  up  digestive  disturbances  when  the  boiling  of  the 
milk  is  stopped.  It  was  formerly  the  author's  routine  pro- 
cedure to  boil  the  milk  for  intestinal  indigestion  and  to  con- 
tinue this  diet  for  two  to  four  weeks  after  the  digestive 
disturbances  had  been  overcome,  then  change  to  the  unboiled 
food.  For  a  few  days  after  this  change  is  made  some  infants 
will  have  stools  which  are  normal  in  character  except  for  a 
few  large,  tough,  beanlike  curds,  which  appear  in  almost 
every  stool  and  which  seem  to  cause  no  discomfort  nor  other 
adverse  symptoms.  Other  infants  will  get  up  a  rather  severe 
intestinal  indigestion  and  diarrhoea  either  immediately  after 
the  change  from  boiled  to  unboiled  milk  or  three  or  four  days 
later.  The  author  has  seen  digestive  disturbances  and  diar- 
rhoea occur  in  so  many  cases  as  a  result  of  the  change  from 
boiled  to  raw  milk,  that  there  is  no  question  as  to  the  cause, 
although  many  well  infants  with  a  normal  digestive  capacity 
stand  the  change  very  well;  in  fact,  by  far  the  majority 
of  them  do. 


BOILED  MILK  IN  INFANT  FEEDING         281 

CASE  LXXI 

(Illustrating  the  manner  in  which  curds  repeatedly  occur  in  the  stools  when 
raw  milk  is  substituted  for  boiled  milk) 

December   18:     Age,  one  month.     Birth  weight,  6  Ib.  2  oz. 

Present  weight,  8  Ib.  2  oz. 
Gain  since  birth,  2  Ib. 

General  Condition. — Well  nourished,  well  developed. 
Stools. — Normal. 
Vomiting. — None. 
A  ppetite. — Good. 
Sleep. — Good. 
Temperature,  normal. 

Previous  Food. — Since  birth  had  been  fed  on  boiled  milk  mixtures,  gradually 
increased  to 

Milk    16  oz.  )  Fed  4  ounces  every  three  hours, 

'  boiled 


I  }  boil 


Water   16  oz.  f  seven    feedings   in  twenty-four 

Dextri-maltose. .      1  oz.  hours. 


Treatment. — Food  prescribed : 

Milk    16  oz.  )  Feed    4    ounces    every    three 

Water  16  oz.  [  unbo  hours  as  before. 

Dextri-maltose   . .      1  oz. 

December  24    (6  days  later)  :     Weight,  8  Ib.  8  oz. 

Gain,  6  oz. 

General  Condition. — The  same. 

Stools. — For  five  days  has  had  two  rather  foul  stools  a  day,  containing  tough, 

hard  curds. 

Vomiting. — A  little  after  each  feeding. 
Appetite. — Good. 
Sleep. — Good;  cries  a  little. 
Temperature,  normal. 
Treatment. — Boil  the  food. 

December  25  ( 1  day  later ) :     Weight,  8  Ib.  8  oz. 

General  Condition. — The  same. 

Stools. — Two  normal  a  day. 

Vomiting. — None. 

Appetite. — Good. 

Sleep. — Good ;  does  not  cry  very  frequently. 


282  SIMPLIFIED  INFANT  FEEDING 

Treatment. — Try  giving  milk  raw  again. 

January  4  <10  days  lajter)  :     Weight,  9  Ib.  8  oz. 

Gain,   1   Ib. 

General  Condition. — The  same. 

Stools. — Twenty-four  hours  after  beginning  to  give  raw  milk  the  curds  appeared 
in  the  stools,  and  continued  throughout  the  period. 

Vomiting. — Very  little  after  each  feeding. 

Appetite. — Good. 

Sleep. — Good;  cries  occasionally. 

Treatment. — Temporarily  boil  the  milk  again  to  reduce  curds.  Since  the 
infant  was  gaining  steadily  in  weight  and  had  no  other  symptoms  of  indi- 
gestion, the  raw  milk  was  resumed  after  twenty-four  hours. 

January  11    (7  days  later)  :     Weight,  9  Ib.  15  oz. 

Gain,  7  oz. 

General  Condition. — The  same. 

Stools. — Curds  reappeared  within  twenty-four  hours  of  giving  unboiled  milk, 

but  grew  gradually  less  during  the  week. 
Appetite. — Good. 
Sleep. — Good. 
Vo  mitin  g. — None. 
Treatment. — Food  unchanged. 

January  16  (1  month  from  beginning  of  experiment)  :     Weight,  10  Ib.  2  oz. 

Gain,  2  Ib. 

After  these  repeated  alternations  between  boiled  and  raw  milk,  the  infant 
continued  to  gain  in  weight  and  thrive  normally  upon  the  unboiled  milk. 

From  observation  and  repeated  experiment,  it  is  very 
evident  that  infants  who  have  been  kept  on  boiled  milks  for 
a  very  long  time  are  more  easily  affected  when  the  boiling 
is  stopped. 

CASE  LXXII 

{In  which  boiled  milk  feedings  had  to  be  used  throughout  the  bottle  period 
because  raw  milk  caused  severe  intestinal  indigestion) 

Twins.  Birth  weight,  unknown. 

April  5:     Age,  6  months.     A's  weight,  13  Ib.  14  oz. 
B's  weight,  14  Ib.  2  oz. 


BOILED  MILK  IN  INFANT  FEEDING         283 

General  Condition. — Normal,  well-nourished  infants. 

Stools. — Two  normal  a  day. 

Vomiting. — None. 

Appetite. — Good. 

Sleep. — Good. 

Temperature,  normal. 

Previous  Food. — Had  been  breast-fed1  up  to  six  weeks  of  age.  Were  then  given 
boiled  milk  mixtures,  with  occasional  feedings  of  raw  milk,  which  always 
caused  indigestion.  Were  now  so  well  and  strong  that  it  seemed  unneces- 
sary to  continue  boiling  the  milk. 

Treatment. — Give  raw  milk. 

April  8    (3  days  later)  :     A's  weight,  13  Ib.  15  oz. 
B's  weight,  14  Ib.     4  oz. 
General  Condition. — The  same. 
Stools. — A  had  three  to  four  loose  stools  a  day,  containing  mucus  and  curds. 

B  had  three  normal  stools  a  day. 
Vomiting. — None. 
Appetite. — Good. 

Sleep. — Fair;  both  cry  more  than  usual. 
Treatment. — Continue  raw  milk. 

April   10    (2  days  later)  :     A's  weight,  13  Ib.  15  oz. 

B's  weight,  14  Ib.     5  oz. 
General  Condition. — The  same. 

Stools. — B  developed  diarrhoea.    A's  stools  remained  the  same. 
Vomiting. — None. 
Appetite. — Good. 

Sleep. — Good  at  night;  appear  restless  during  the  day,  with  evidences  of  colic. 
Treatment. — Continue   raw   milk  for  twenty-four   hours   longer  only,   unless 
stools  improve. 

April  14   (4  days  later)  :     A's  weight,  14  Ib.  1  oz. 
B's  weight,  14  Ib.  5  oz. 

The  stools  gradually  got  worse  until  there  were  five  or  six  mucous,  curdy, 
watery  stools  a  day,  with  a  great  deal  of  restlessness  and  evident  colic  and  a 
cessation  of  gain  in  weight.  The  milk  was  given  boiled. 

April    19    (5    days    later)  :     A's  weight,  14  Ib.  3  oz. 

B's  weight,  14  Ib.  8  oz. 

It  proved  to  have  been  a  very  severe  intestinal  indigestion,  and  it  was  five 
days  before  the  bowels  again  became  normal  and  the  infants  seemed  happier. 

For  this  reason  the  boiled  milk  was  continued  until  the  infants  were  eight 
months  of  age,  when  with  difficulty  they  were  weaned  to  raw  milk. 


284  SIMPLIFIED  INFANT  FEEDING 

In  two  other  cases,  giving  only  two  feedings  of  unboiled 
milk  a  day,  the  rest  being  boiled,  caused  a  diarrhoea  which 
stopped  when  the  boiling  of  the  entire  feedings  was  resumed. 
After  one  case  of  the  series  had  been  fed  boiled  milk  for  one 
month,  two  feedings  a  day  were  given  unboiled,  as  the  bowels 
were  constipated.  Three  or  four  days  thereafter  the  stools 
showed  a  good  deal  of  mucus  and  curds,  and  the  boiling  was 
resumed,  with  the  usual  result  that  the  stools  became  normal 
again.  A  week  later  two  feedings  a  day  were  again  given 
unboiled,  the  rest  being  boiled,  and  again  a  diarrhoea  devel- 
oped. This  same  experience  was  repeated  in  another  infant, 
after  the  boiled  milk  feedings  had  been  used  continuously 
for  seven  months. 

It  is  impossible  to  prophesy  whether  the  change  from 
boiled  to  unboiled  milk  is  going  to  cause  digestive  disturb- 
ances in  an  individual  infant  or  not.  Undoubtedly  those  in- 
fants who  have  been  most  difficult  to  feed  and  have  had  fre- 
quent attacks  of  intestinal  indigestion  are  more  liable  to  get 
up  diarrhoea  when  the  boiling  is  stopped.  The  criticism 
naturally  might  be  made  that  some  or  all  of  these  diarrhoeas 
were  due  to  an  infection,  but,  in  the  first  place,  the  course 
and  symptomatology  is  never  that  of  an  infectious  diar- 
rhoea, as  there  is  no  temperature  nor  other  evidence  of  tox- 
aemia. In  the  second  place,  certified  milk  was  used  and  every 
precaution  taken  in  the  proper  icing  of  the  milk,  care  of  the 
bottles,  nipples,  etc.,  in  many  instances  by  a  trained  nurse 
who  is  thoroughly  familiar  with  the  dangers  of  milk 
infection. 

A  very  interesting  experiment  was  conducted  some  years 
ago,  during  the  summer,  in  the  Babies'  Wards  of  the  New 
York  Post-Graduate  Hospital.  There  were  thirty  cases  of 
various  kinds  of  gastro-enteritis  that  were  being  bottle-fed 
in  the  wards.  Boiled  milk  had  been  given  as  a  routine  for 
two  weeks  with  varying  success,  although  not  a  single  one  of 
the  infants  had  any  tough,  hard  curds  in  the  stools.  A 


BOILED  MILK  IN  INFANT  FEEDING         285 

sweeping  order  was  given  to  stop  boiling  the  milk,  and  in 
every  instance  the  curds  appeared.  In  three  days  another 
sweeping  order  was  given  to  boil  all  the  milks,  and  in  twenty- 
four  to  thirty-six  hours  the  stools  of  all  the  infants  were  free 
of  curds.  This  result  has  been  repeated  so  frequently  in  the 
author's  experience  that  there  can  be  no  doubt  in  his  mind 
that  changing  from  boiled  to  unboiled  milk  is  a  cause  of 
digestive  disturbances. 

Does  Boiled  Milk  Aid  us  in  Overcoming  Digestive  Disturb- 
ances Such  as  Intestinal  Indigestion,  with  or  without  Diarrhoea, 
or  Vomiting? — There  are  so  many  different  factors  that  enter 
into  the  treatment  of  the  various  digestive  disturbances 
that  one  must  be  careful  when  he  attributes  his  success  in 
treating  a  single  case  or  a  series  of  cases  to  any  single  one  of 
these  factors,  such  as  the  boiling  of  the  milk.  The  intervals 
between  the  feedings,  the  quantity  at  a  feeding,  the  caloric 
value  of  the  food,  the  amount  and  kind  of  sugar  used,  the 
addition  of  starches  or  dextrinized  starches,  the  dilution,  the 
percentages  of  fat  and  proteid,  the  kind  of  milk  used,  the 
proper  preparation  of  the  food  and  carrying  out  of  the  direc- 
tions, all  play  an  important  part  in  overcoming  digestive 
disturbances.  It  may  be  assumed  that  intestinal  or  gastric 
indigestion  cannot  be  influenced  by  any  procedure  when  the 
details  are  not  properly  carried  out. 

It  has  been  my  custom  to  begin  the  treatment  of  almost 
all  my  cases  of  simple  intestinal  indigestion  (and  this  does 
not  include  cases  of  infectious  gastro-enteritis)  with  a  mix- 
ture of  about  one-third  milk  and  two-thirds  water,  boiled 
as  above  described.  No  starch  or  sugar  or  alkali  is  added 
to  the  mixture.  The  simplicity  of  this  procedure  and  the 
almost  universal  application  of  it  eliminates  many  compli- 
cating problems,  and,  since  it  is  almost  always  successful 
in  overcoming  the  digestive  disturbances  in  the  proper  class 
of  cases,  it  is  fairly  easy  to  determine  whether  the  boiling 
of  the  milk  is,  in  part  at  least,  responsible  for  the  good  results 


286  SIMPLIFIED  INFANT  FEEDING 

obtained.  It  is  very  evident  that  many  cases  of  intestinal 
indigestion  cannot  be  successfully  treated  with  this  mixture 
unboiled. 

CASE  LXXIII 

(In  which  the  stools  were  made  normal  by  boiling  the  milk  without  changing 
the  food  in  any  other  way) 

May  4 :     Age,  4  months  2  weeks.     Birth  weight,  9  Ib.  8  oz. 

Present  weight,  10  Ib.  8  oz. 
Gain  since  birth,  1  Ib. 
General  Condition. — Very  poorly  nourished;   rough  skin;  malnutrition;  good 

bony  development. 

Stools. — Six  or  seven  green,  watery,  mucous,  curdy  stools  in  twenty-four  hours. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 
Temperature,  98.6°  F. 
Chief  Complaint. — Diarrhoea. 

Previous  Food. — 

Milk 18  oz.)  .  Fed  5-  ounces  every  three  hours, 

„  ,  -D        }-  temporarily  unboiled  ...        : ,     _.  , 

Water 18  oz.  j  seven  feedings  in  24  hours. 

Treatment. — Boil  the  food. 

May  7    (3  days  later) :     Weight,   10  Ib.  9  oz. 

Gain,  1  oz. 

'General  Condition. — The  same. 
Stools. — Two  soft,  yellow,  homogeneous  stools. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Good. 
Treatment. — Continue  boiling  the  food. 

The  bowels  remained  normal  and  the  infant  improved  as  the  milk  was 
increased  and  sugar  added. 

In  fifty-two  cases  of  diarrhoea  from  intestinal  indigestion 
which  were  treated  with  boiled  milk  mixtures  the  stools  be- 
came normal  in  from  two  to  five  days.  The  ages  varied 
from  three  weeks  to  one  year.  The  stools  varied  from  three 
to  twenty  per  day,  all  of  them  showing  evidences  of  indi- 
gestion and  most  of  them  containing  mucus  and  curds.  As 
many  of  these  cases  were  treated  in  summer  as  in  winter. 
The  weights  varied  from  four  pounds  five  ounces  to  nineteen 


287 

pounds  four  ounces,  the  majority  of  them  being  small,  emaci- 
ated, young  infants.  The  previous  feeding  varied  from 
simple  barley  gruel,  which  in  some  cases  had  been  used  for  a 
prolonged  period  without  overcoming  the  diarrhoea,  to  the 
more  complicated  top  milk  and  whey  mixtures  and  the 
various  proprietary  foods.  There  were  all  classes  of  intes- 
tinal indigestion,  but  no  acute  infectious  diarrhoeas  included 
in  the  group,  as  such  cases  have  too  many  complicating  ele- 
ments to  be  of  any  value  in  deciding  whether  boiled  milk  is 
more  easily  digested  than  unboiled  milk  in  the  average  in- 
fant. However,  it  may  be  said  in  passing  that  if  boiled  milk 
is  more  easily  digested  than  unboiled  milk  it  should  naturally 
follow  that  cases  of  acute  infectious  diarrhoea  which  require 
milk  feeding  should  receive  the  milk  boiled. 

The  series  of  cases  in  which  the  unboiled  milk  was  used 
in  the  same  dilution  is  small,  because  of  the  poor  results 
obtained,  as  it  did  not  seem  fair  to  the  infants  to  allow  them 
to  continue  with  the  unboiled  milk  when  the  stools  did  not 
improve  under  this  treatment.  A  typical  case  treated  with 
unboiled  milk  is  as  follows : 

CASE  LXXIV 

(Illustrating  intestinal  indigestion  in  which  the  diarrhoea  persisted  with 
raw  milk  mixtures,  but  was  promptly  relieved  upon  boiling  the  same 
mixture) 

August   1 :     Age,  4  months.     Birth  weight,  unknown. 

Present  weight,  9  Ib.  14  oz. 

General  Condition. — Poorly  nourished;  good  bony  development;  smooth  skin. 
Stools. — Three  loose,  watery  stools  a  day,  with  much  mucus  and  many  curds. 
Vomiting. — A  great  deal  at  every  feeding. 
Appetite. — Ravenous. 
Sleep. — Poor. 
Temperature,  98.6°  F. 

Previous  Food. — 

10  per  cent,  top  milk...     5  oz-\^-i  j  Fed    3-f    ounces    every 

Water 20  oz.  j  three     hours,     seven 

Lime  water 2  teaspoonf uls  feedings  in  24  hours. 

Milk  sugar 4  teaspoonfuls 


288 

Treatment. — Food  prescribed: 

Milk.. 10  oz.1  Feed    4    ounces    every    three 

I  unboiled 
Water 20  oz.  f  hours  as  before. 

Sugar 0 

August  7    (6  days  later) :     Weight,  10  Ib.  2  oz. 

Gain,  4  oz. 

General  Condition. — The  same. 
Stools. — Unchanged,  except  that  curds  became  hard  and  tough  instead  of  soft 

as  before. 

Vomiting. — Continues. 
Appetite. — Still  hungry. 
Sleep. — Poor. 
Treatment. — Food  unchanged  in  substance  or  quantity,  but  boiled. 

In  three  days  the  stools  became  smooth,  homogeneous,  and  free  f  om  curda 
and  mucus. 

There  were  ten  cases  in  this  series  which  included  the 
same  kind  of  infants  as  in  the  boiled  milk  series.  In  only  two 
did  the  stools  clear  up  without  resorting  to  the  boiled  milk, 
and  those  were  infants  who  had  formerly  been  receiving  ex- 
tremely bad  feeding,  one  a  very  high  fat  and  the  other  very 
high  sugar.  In  the  other  eight  the  diarrhoea  was  allowed 
to  go  on  for  seven  days  in  three  cases,  nine  days  in  three 
cases,  and  twelve  days  in  two  cases,  before  the  boiled  milk 
feedings  were  instituted.  In  all  of  these  cases  the  stools  be- 
came normal  inside  of  five  days  after  beginning  the  boiled 
milk. 

These  boiled  milk  mixtures  are  particularly  useful  in  the 
small,  young,  poorly-nourished  infants,  who  do  not  do  well 
on  an  exclusive  carbohydrate  diet,  such  as  is  so  frequently 
given  for  a  few  days  before  starting  milk  feedings.  It  is 
probably  the  experience  of  all  of  us  that  the  older,  well- 
nourished  infants,  say  above  six  months  of  age,  who  have 
intestinal  indigestion,  are  best  treated  with  either  an  entire 
cessation  of  food  for  twelve  to  twenty-four  hours,  or  a  starch 
diet,  such  as  the  various  gruels  and  perhaps  bread  pap. 
But  the  younger,  smaller  infants  and  those  with  malnutrition 
who  are  suffering  from  the  lack  of  food  do  not  do  well  with 


BOILED  MILK  IN  INFANT  FEEDING         289 

this  treatment.  It  is  not  an  uncommon  experience  to  see 
infants  of  this  class  who  have  been  fed  barley  gruel  for  a 
period  of  a  week  or  more  with  no  improvement  in  the  stools 
and  with  a  marked  loss  in  weight  and  strength. 

It  is  not  easy  to  determine  the  effect  of  boiled  milk  on 
the  gastric  digestion.  Cases  of  severe  vomiting  were  stopped 
or  the  severity  much  diminished  when  boiled  milk  mixtures 
were  given  in  simple  dilutions.  However,  this  generally 
occurred  in  infants  who  came  under  observation  for  the  first 
time,  and  whose  feeding  had  previously  been  more  or  less 
irrational.  Beside  that,  the  sugar  is  usually  cut  down  in 
amount  and  many  other  proper  changes  are  made. 

On  the  other  hand,  there  are  certain  infants  whose  vomit- 
ing does  not  stop  with  the  boiling  of  the  milk,  but  in  the 
author's  experience,  at  least,  vomiting  has  never  been  caused 
by  the  change  from  unboiled  to  boiled  milk,  or  vice  versa. 
Undoubtedly  the  large,  tough  curds  that  are  seen  in  the 
stools  of  some  infants  fed  with  unboiled  milk  are  originally 
formed  in  the  stomach,  and  unboiled  milk  stays  in  the 
stomach  longer  than  boiled  milk,  both  of  which  facts  are 
shown  by  Brennemann. 

Does  Boiled  Milk  Cause  Constipation? — Constipation  in  the 
bottle-fed  has  so  many  different  causes  that  it  is  difficult  to 
prove  what  part  the  boiling  of  the  milk  plays  in  its  etiology. 
In  many  infants  who  were  constipated  when  the  boiled 
milks  were  started  the  constipation  was  overcome  during  the 
period  that  the  boiled  milk  was  fed.  In  others  the  consti- 
pation persisted  with  the  boiled  milk  feeding,  but  was  re- 
lieved when  unboiled  milk  was  given.  Still  others  who  were 
constipated  on  the  boiled  milk  feeding  were  just  as  consti- 
pated after  the  feeding  was  changed  to  unboiled  milk.  None 
of  the  babies  who  received  the  malt  soup  extracts  were  con- 
stipated at  any  time  while  taking  this  food,  which  shows 
that,  even  if  constipation  is  caused  by  boiled  milk  and  water 
mixtures,  adding  certain  elements  to  the  food  will  overcome 

19 


290  SIMPLIFIED  INFANT  FEEDING 

the  trouble  in  spite  of  the  boiling.  Infants  who  have  diar- 
rhoea for  which  boiled  milk  is  instituted  often  acquire  a 
much-welcomed  constipation.  The  constipation  is  then 
usually  overcome  as  sugar  is  added  to  the  food  and  as  the 
food  is  increased  in  quantity  and  strength. 

Of  the  thirty-one  infants  who  were  constipated  at  some 
time  while  they  were  receiving  boiled  milk  as  a  food,  in  nine- 
teen the  constipation  was  overcome  before  the  food  was 
changed  to  unboiled  milk,  in  six  the  constipation  was  relieved 
by  stopping  the  boiling,  and  in  six  others  the  constipation 
persisted  in  spite  of  the  change  from  boiled  to  unboiled  milk. 

It  would  seem,  then,  that,  although  constipation  more 
frequently  occurs  in  infants  fed  upon  boiled  milk,  in  certain 
cases  it  may  be  overcome  while  the  baby  is  fed  upon  boiled 
milk,  and  that  stopping  the  boiling  does  not  always  stop  the 
constipation. 

Is  Boiled  Milk  as  Readily  Assimilated  as  Unboiled  Milk,  or  is 
the  Nutritional  Value  of  Milk  Lessened  by  Boiling? — This  is  a 
phase  of  the  question  that  cannot  be  decided  by  clinical 
work.  There  is  a  certain  loss  of  fat  and  proteid  when  scum 
is  allowed  to  form  on  the  top  of  the  milk,  but  if  it  is  stirred 
constantly  and  brought  rapidly  to  a  boil  this  scum  is  not 
formed.  Even  with  this  detail  carried  out,  there  is  probably 
a  small  loss  in  the  nutritional  value  of  the  milk.  The  only 
evidence  (which  is  not  at  all  conclusive)  is  based  upon  the 
increase  in  the  infant's  weight  on  stated  amounts  of  boiled 
and  unboiled  milk. 


CHAPTER  XXIII 

DRY  MILK 

DRY  milk  is  a  powder  made  from  fresh  cow's  milk  by 
the  evaporation  of  the  water.  The  liquid  milk  is  instanta- 
neously dried  as  it  flows  over  hot  revolving  cylinders  and  in 
its  dry  state  contains  all  of  the  original  elements  except 
water.  The  powder  is  put  up  in  cans  and  is  readily  prepared 
for  feeding  purposes  by  dissolving  it  in  hot  water. 

Bonnamour  fed  fifty-six  infants  over  prolonged  periods 
on  dry  milk.  He  found  that  dry  milk  was  extremely  useful 
and  especially  valuable  in  cases  of  sickly  infants,  who,  while 
unable  to  digest  milk  in  other  forms,  could  yet  take  dry  milk 
readily  and  make  good  progress.  He  states  that  he  had  only 
met  five  cases  of  intolerance  to  dry  milk  in  the  course  of 
eight  years'  experience  and  expressed  himself  converted 
from  a  former  state  of  doubt  as  to  the  value  of  dry  milk. 

Naish  says, ' 'I  have  followed  up  a  considerable  number  of 
infants  fed  on  dried  milk,  and  I  am  personally  convinced  that 
there  is  no  more  risk  of  rickets  with  this  diet  than  with  a 
good  quality  of  raw  cow's  milk."  He  also  states  that  it  is 
possible  to  cure  rickets  by  changing  a  previously  given  diet 
to  a  dry  milk  diet. 

C.  Killick  Millard  states :  "It  was  very  soon  discovered, 
however,  that  dry  milk  had  one  most  important  advantage- 
greater  digestibility — and  that  many  infants  would  retain  it 
and  at  once  begin  to  thrive  who  previously  had  been  con- 
tinuously subject  to  vomiting  after  each  feeding  and  in 
consequence  were  making  little  or  no  progress.  ...  A 
careful  watch  has  been  kept  for  any  bad  effects,  such  as 
scurvy  or  rickets,  but  although  I  have  had  experience  of 
some  hundreds  of  infants  fed  on  it  for  periods  ranging  up 
to  ten  months,  or  even  longer,  so  far  none  have  been  seen. 

291 


292  SIMPLIFIED  INFANT  FEEDING 

Inquiries  have  also  been  made  from  fifteen  medical  men  prac- 
ticing in  the  districts  whence  most  of  the  cases  have  been 
drawn,  and  their  replies  in  all  cases  were  favorable  to  the 
use  of  dry  milk,  and  support  the  conclusions  that  no  bad 
effects  have  followed." 

Dry  milk  has  long  been  used  in  the  so-called  proprietary 
foods,  among  them  Nestle 's  Food,  Allenbury's  Food,  Mam- 
mala,  Malted  Milk,  and  so  forth.  The  main  fault  that  could 
be  found  with  these  preparations  is  that  most  of  them  contain 
other  ingredients  besides  cow's  milk.  Nestle 's  food,  for  in- 
stance, is  stated  on  the  package  to  be  '  *  a  compound  of  milk, 
baked  wheat  flour,  wheat  malt  and  sugar  only. ' '  Allenbury  's 
food  is  stated  by  the  manufacturer  to  be  made  of  milk,  cream 
and  milk  sugar  modified  to  "  imitate  the  percentages  of 
breast  milk, '  *  evaporated  in  vacuo  and  sold  in  powder  form. 
Mammala  is  stated  by  the  manufacturers  to  contain  fifty- 
four  per  cent,  of  milk  sugar,  and  most  of  the  malted  milks 
contain  a  large  percentage  of  maltose  and  dextrine  besides 
the  dry  milk. 

One  can  readily  see  the  advantages  of  a  dry  milk  which 
has  nothing  added  to  it,  neither  sugar  nor  starch,  for  many 
infants,  especially  the  difficult  feeding  cases,  have  an  intoler- 
ance for  the  various  sugars  or  for  starch,  and  dry  millr 
which  has  no  sugar  or  other  ingredients  added  to  it  will  be 
more  easily  digested  and  therefore  superior  to  any  of  those 
preparations  that  are  sold  with  the  sugar  or  starch  already 
mixed  in  it.  On  the  other  hand,  the  addition  of  these  ingredi- 
ents may  be  ordered  if  any  of  them  are  considered  necessary 
for  the  individual  at  hand. 

It  has  been  the  author's  clinical  observation  that  dry 
milk  is  better  tolerated  by  those  infants  who  have  already 
received  a  food  injury,  than  raw  milk  or  boiled  milk  mixtures. 
These  observations  were  originally  based  upon  a  close  study 
of  over  fifty  cases  in  private  practice  which  were  followed 
over  a  prolonged  period  with  the  utmost  care.  Since  then 


DRY  MILK 


293 


the  series  has  been  much  larger  and  the  same  conclusions 
hold  true.  It  is  usually  wise  to  turn  to  the  use  of  dry  milk 
as  soon  as  it  is  found  that  the  individual  infant  does  not 
prosper  upon  ordinary  milk  mixtures  of  fresh  liquid  milk. 
Often  with  the  change  to  dry  milk  the  improvement  is 
marked,  and  in  many  instances,  the  relief  from  digestive 


Week  of  age. 

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symptoms  is  immediate.  Without  exception,  in  all  of  the 
cases  where  there  was  no  organic  disturbance,  such  as  pyloric 
stenosis,  tuberculosis,  syphilis,  etc.,  the  results  have  been 
surprisingly  good.  Vomiting  is  often  .controlled  within 
twenty-four  hours,  intestinal  indigestion  immediately  over- 
come and  an  increase  in  weight  begun  at  once. 

In  the  composite  weight  chart  "A"  represents  the  weight 
curve  of  a  normal  infant  (Holt)  and  "  B  "  the  average  weight 
of  my  fifty  cases.  When  the  dry  milk  was  begun  they  aver- 


294  SIMPLIFIED  INFANT  FEEDING 

aged  three  and  one-half  pounds  below  the  normal,  whereas 
the  average  weight  had  reached  the  normal  point  when  the 
food  was  discontinued  or  other  foods  begun. 

CASE  LXXV 

(Illustrating  the  use  of  Dry  Milk  where  the  usual  milk  mixtures  disagreed) 
October  15:     Age,  9  months.     Birth  weight,  6  Ib.  3  oz. 

Present  weight,  9  Ib.  11  oz. 
General  Condition. — Poorly  nourished. 
Stools. — Two  firm  normal. 

Vomiting. — Good  deal  after  almost  every  feeding. 
Appetite. — Good. 

Sleep. — Restless,  fretful,  slept  but  little  in  daytime. 
Temperature,  98.6°  F. 
Chief  Complaint. — Failure  to  gain. 

Previous  Food: 

Breasfc-fed  the  first  month,  then  malted  milk  mixtures,  and  for  tae  last 
five  months  he  has  been  very  intelligently  fed  with  fresh  milk  modifications 
with  various  sugars,  but  without  great  success. 
Treatment. — Food  prescribed : 

Dry  milk   2  tablespoonfuls      Feed  6  oz.  every  3  hours,  at  6,  9, 

Water 6  oz.  12  A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

Every  second  day  increase  the  drj  milk  one  tablespoonful,  up  to  five 
tablespoonfuls,  in  6  oz.  of  water. 

October  22  (7  days  later)  :     Weight,  10  Ib.  8  oz. 

Gain,  13  oz. 

General   Condition. — Improved. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 
Treatment. — Food  prescribed : 

Food  unchanged. 

The  vomiting  was  much  diminished  from  the  start  and  after  a  week  it 
practically  ceased.  There  was  a  continuous  gain  in  weight,  and  on  January 
16th,  three  months  later,  the  baby  weighed  eighteen  pounds  six  ounces,  a  gain 
of  over  seven  pounds  in  three  months. 

There  are  comparatively  few  facts  to  learn  in  using  dry 
milk;  in  fact,  the  simplicity  of  the  whole  procedure  is  one 
of  its  desirable  features. 

The  food  must  be  made  fresh  at  each  feeding  by  dissolv- 
ing the  proper  quantity  of  the  dry  milk  powder  in  the  proper 


DRY  MILK  295 

quantity  of  hot  water.  In  order  to  furnish  fifty  calories  per 
pound  per  day  give  three  tablespoonfuls,  levelled  with  a 
knife,  of  dry  milk  for  every  pound  of  the  body  weight,  since 
a  tablespoonful  has  sixteen  calories.  For  example,  a  seven- 
pound  infant  needs  in  twenty-four  hours  twenty-one  table- 
spoonfuls.  If  the  infant  is  given  seven  feedings  a  day 
(three-hour  intervals)  each  feeding  would  therefore  con- 
tain three  tablespoonfuls  of  dry  milk. 

As  a  matter  of  fact,  only  very  poorly  nourished  infants 
need  as  many  as  fifty  calories  per  pound  of  dry  milk.  Well- 
nourished  or  fat  babies  gain  progressively  on  forty  calories 
per  pound  per  day  (or  even  less),  which  can  be  furnished 
in  two  and  a  half  tablespoonfuls  for  each  pound  of  the  body 
weight.  The  reason  for  this  low  caloric  requirement  is  that 
dry  milk  is  more  easily  digested  and  is  probably  more  fully 
utilized  than  raw  milk,  and  less  energy  is  required  for  the 
digestive  processes. 

The  maximum  strength  of  the  food  is  one  tablespoonful 
to  the  ounce  of  water,  weaker  solutions  always  being  used 
at  first. 

When  beginning  dry  milk  with  an  infant  that  has  already 
had  marked  digestive  disturbances  or  a  food  injury,  it  is 
advisable  to  give  much  less  than  the  infant  actually  needs 
and  increase  the  tolerance  just  as  you  would  writh  any  other 
food,  although  it  is  noticeable  that  the  tolerance  is  much 
more  quickly  increased  for  dry  milk  than  it  is  for  fresh 
cow's  milk  or  sugar.  Begin  with  one  tablespoonful  (one- 
eighth  of  an  ounce  by  weight)  in  two  to  four  ounces  of  water, 
according  to  the  age  and  size  of  the  infant.  In  twenty-four 
hours  two  tablespoonfuls  to  each  feeding  may  be  used  and  a 
day  or  two  later  three  tablespoonfuls,  and  so  on  until  the 
caloric  requirements  are  fulfilled.  An  infant  of  average 
size  and  weight  may  have  at  each  feeding  one  or  two  more 
ounces  of  food  than  the  number  of  months  of  its  age  with 
a  minimum  quantity  of  three  ounces  and  a  maximum  of  eight 


296  SIMPLIFIED  INFANT  FEEDING 

ounces.  Undersized  or  vomiting  infants  must  have  less. 
This  method  of  increasing  the  tolerance  is  well  illustrated  in 
the  following  case : 

CASE  LXXVI 

(Illustrating  rapid  increase  in  tolerance  when  using  Dry  Milk) 
July  2:     Age,  2  months.     Birth  weight,  8  Ib.  6  oz. 

Present  weight,  8  Ib.  1  oz. 
General  Condition. — Poorly  nourished. 
Stools. — Five  to  six  green,  watery,  with  mucus. 
Vomiting. — Good  deal  after  each  feeding. 
Appetite. — Hungry. 
Sleep. — Restless. 
Temperature,  98.6°  F. 
Chief  Complaint. — Sleepiness,  vomiting,  loose  stools,  failure  to  gain. 

Previous  Food: 

He  was  breast-fed  the  first  two  weeks  of  life  and  since  then  had  Imperial 
granum,  malt  soup  and  various  other  modifications  of  cow's  milk. 
Treatment. — Food  prescribed : 

Dry  milk 1  tablespoonful      Feed   three    ounces    every    three 

Water    3  oz.  hours,  seven  feedings  in  twenty- 

four  hours,   at  6,   9,    12   A.M., 
3,  6,  9  P.M.,  2  A.M. 
July  3:     Weight,  8  Ib.  2  oz. 
General  Condition. — Same. 
Stools. — Three  green  loose,  no  mucus. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep. — Poor. 

Treatment . — Food  prescribed : 

Dry  milk   2  tablespoonfuls      Feed  3  oz.  every  3  hours  at  6,  9, 

Water 3  oz.  12  A.M.,  3,  6,  9  P.M.,  2  A.M. 

July  5 :     Weight,  8  Ib.  4  oz. 
Gain,  2  oz 

General  Condition. — Same. 

Stools. — Three  firm,  smooth,  yellow. 

Vomiting. — None. 

Appetite. — Hungry. 

Sleep. — Fair. 

Treatment. — Food  prescribed : 

Dry  milk   3  tablespoonfuls      Feed  3  oz.  every  3  hours  at  6, 

Water 3  oz.  9,  12  A.M.,  3,  6,  9  P.M.,  2  A.M. 


DRY  MILK  297 

July  10:     Weight,  8  Ib.  12  oz. 

Gain,  8  oz.  in  5  days. 
General  Condition. — Improved. 
Stools. — Two  firm  normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Good. 

Treatment. — Food  prescribed  : 

Dry  milk    4  tablespoonfuls      Peed  4  oz.  every  3  hours  at  6,  9, 

Water 4  oz.  12  A.M.,  3,  6,  9  P.M.,  2  A.M. 

The  vomiting  never  recurred,  nor  was  there  any  subsequent  looseness  of 
the  bowels,  and  he  continued  to  gain  progressively  in  weight. 

The  question  invariably  arises  with  any  particular  kind 
of  feeding,  does  it  cause  rickets,  malnutrition,  ansemia  or 
scurvy,  when  used  over  a  long  period  of  time!  In  fact, 
suspicion  always  rests  upon  any  food  which  does  not  contain 
fresh  cow's  milk,  or  even  milk  which  does  not  contain  the 
same  percentage  of  fat  and  protein  as  the  breast  milk.  The 
fundamental  cause  of  rickets  and  scurvy  not  being  known, 
clinical  observation  must  be  relied  upon  to  determine 
whether  a  given  food  does  cause  these  disorders.  Close 
observation  has  shown  definitely  that  neither  low  fats,  the 
pasteurization,  or  the  boiling  of  milk,  directly  causes  scurvy 
or  rickets  when  orange  juice  is  given  in  the  proper  quanti- 
ties, and  the  most  careful  watchfulness  for  such  manifesta- 
tions in  the  infants  to  whom  I  have  given  dry  milk  show  also 
that  the  same  is  true  of  dry  milk.  In  none  of  my  cases  has 
scurvy  or  rickets  originated.  On  the  other  hand,  many  of 
them  had  rickets,  malnutrition  or  anaemia  when  the  dry  milk 
was  instituted,  which,  in  the  course  of  time,  and  often 
with  unusual  promptness,  disappeared.  Hess  has  shown 
that  it  is  wiser  to  give  orange  juice  to  all  bottle-babies,  be- 
ginning as  early  as  six  weeks  of  age,  a«nd  in  this  way  the 
question  of  scurvy  may  be  eliminated.  Therefore,  all  of 
my  series  fed  with  dry  milk  have,  as  a  routine,  received 
orange  juice  by  the  time  they  have  been  on  the  dry  milk  for 
two  or  three  weeks. 


298  SIMPLIFIED  INFANT  FEEDING 

The  very  worst  feeding  case  that  the  author  has  ever 
treated  is : 

CASE  LXXVII 

( Illustrating  the  use  of  Dry  Milk  in  the  worst  feeding  case  imaginable ) 
July  23:     Age,  2  years,  1  month.     Birth  weight,  7  lb.  8  oz. 

Present  weight,  9  lb.  2  oz. 
Gain  in  two  years,  1  lb.  10  oz. 

General  Condition. — Emaciated  to  the  last  degree,  extremely  anemic.  Her 
abdomen  was  distended,  the  bony  development  showed  marked  rickets, 
but  there  were  sixteen  teeth. 

Stools. — One  constipated  with  enema,  but  formerly  whenever  sugar  had  been 
added  to  the  food  there  was  diarrhoea.     This  had  occurred  many  times 
in  the  past  two  years. 
Vomiting. — None. 
Appetite. — Ravenous. 
Sleep. — Good. 
Temperature,  98.6°  F. 

Chief  Complaint. — Emaciation,  recurrent  diarrhoea. 

Previous  Food. — Very  intelligent  bottle  feedings  of  modified  whole  milk  and 
skimmed  milk  mixtures  throughout  the  first  year  and  less  intelligent 
persistence  of  these  mixtures  throughout  the  second  year. 

Treatment. — Food  prescribed : 

Dry  milk 2,  increased  to  4      Feed  5  oz.  every  3  hours,  6 

tablespoonfuls  feedings  in  24  hours  at 

Water 4  oz.  6,  9,  12  A.M.,  3,  6,  10  P.M. 

Thick  barley  jelly ....    1  oz. 
Orange  juice  once  a  day. 

July  30:     Weight,  9  lb.  6  oz. 

Gain,  4  oz. 

General  Condition. — The  same. 
Stools. — Normal. 
Vomiting. — None. 
Appetite. — Hungry. 
Sleep.— Good. 

Treatment. — Food  prescribed: 

Dry  milk 5  tablespoonfuls      Feed  5  oz.  every  3  hours,  at  6,  9, 

Water 3  oz.  12  A.M.,  3,  6,  10  P.M. 

Barley  jelly  ...   2  oz. 

August  6:     Weight,   10  lb.  2  oz. 

Gain,   12  oz.   in  7  days. 

General  Condition. — Improved. 

Stools. — One  normal. 

Vo  m  iting. — None. 

Appetite. — Hungry. 

Sleep. — Good. 


DRY  MILK  299 

Treatment . — Food  prescribed : 

Dry  milk   6  tablespoonfula      Feed  6  oz.  every  3  hours,  at  6,  9, 

Water 3  oz.  12  A.M.,  3,  6,  10  P.M. 

Barley  jelly  ...   3  oz. 

August  13:     Weight,  11  Ib.  2  oz. 

Gain,   16  oz.  in  7  days. 
General  Condition. — Improved. 
Stools. — Two  normal.  , 

Vomiting. — None. 
Appetite. — Satisfied. 
Sleep. — Good. 

Treatment. — Food  prescribed : 

Dry  milk 7  tablespoonfuls      Feed  7  oz.  every  3  hours,  at  6,  9, 

Water 3  oz.  12  A.M.,  3,  6,  10  P.M. 

Barley  jelly  ...   4  oz. 

September  4:     Weight,  13  Ib.  2  oz. 

Gain,  2  Ib.  in  21  days. 
General  Condition. — Much  improved. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Good. 
Sleep. — Excellent. 

On  October  14th,  three  months  later,  she  had  more  than 
doubled  her  weight,  weighing  eighteen  pounds  eight  ounces, 
and  was  in  splendid  physical  condition.  In  the  meantime, 
vegetables  and  cereals  had  been  added  to  the  dry  milk  diet, 
as  her  powers  of  digestion  increased. 

The  theoretical  reasons  for  the  ready  digestibility  of 
dry  milk  deserve  consideration.  First,  and  perhaps  most 
important,  is  the  change  which  takes  place  in  the  casein  dur- 
ing the  process  of  drying.  The  heat  and  the  loss  of  water 
separates  almost  instantaneously  the  casein  into  minute 
particles  which  remain  suspended  in  this  finely  divided  state, 
when  water  is  later  added  for  feeding  purposes.  In  the 
stomach  these  separate  particles  do  not  unite  to  form  large 
masses  or  curds,  such  as  are  found  when  fresh  cow's  milk 
is  acted  upon  by  the  gastric  juice.  Instead  they  become 
swollen  in  the  stomach  but  remain  separate  particles,  which 
are  not  only  more  easily  attacked  by  the  gastric  juice,  but 


300  SIMPLIFIED  INFANT  FEEDING 

when  they  pass  into  the  alkaline  medium  of  the  intestines, 
where  the  greater  part  of  the  digestion  takes  place,  these 
fine  particles  are  digested  much  more  readily  than  the  large 
curds  of  fresh  cow's  milk,  or  even  the  small  curds  of 
boiled  milk. 

The  preparation  of  dry  milk  which  the  author  has  used 
contains  a  low  fat,  that  is,  12  per  cent,  in  the  dry  milk 
powder.1  This  is  probably  one  reason  that  infants  who  have 
had  an  injury  or  indigestion  due  to  fat,  take  care  of  it  more 
easily  than  they  do  the  ordinary  milk  mixtures.  Besides 
that,  dry  milk  contains  a  larger  proportion  of  free  fatty  acid 
than  does  fresh  cow's  milk.  These  fatty  acids  react  with 
the  alkaline  carbonates  to  form  soaps  and  the  soaps  in  turn 
form  an  emulsion,  which  assists  in  the  digestion  of  the  fats. 

Besides  the  question  of  the  proteins  and  the  fats,  the 
sugar  of  dry  milk  presents  a  very  interesting  problem.  When 
first  using  dry  milk,  the  author  was  surprised  to  find  that 
dry  milk  and  water  alone  proved  to  be  a  well-balanced  feed- 
ing. In  other  words,  the  babies  gained  and  prospered  with- 
out any  additional  sugar,  starch  or  other  carbohydrates. 
We  know  that  fresh  cow's  milk  alone,  without  the  addition  of 
carbohydrates,  is  not  a  well-balanced  ration,  at  any  age, 
and  it  is  almost  impossible  to  make  an  infant  gain  contin- 
uously in  weight  without  either  the  addition  of  sugar  or 
starch.  However,  dry  milk  alone  mixed  with  water,  one  part 

1Dryco  Brand  dry  milk  made  by  the  Dry  Milk  Company,  15  Park  Bow, 
New  York  City. 

APPROXIMATE  ANALYSIS 

Per  cent. 

Fat  12 

Lactose    44 

Protein    34 

Salts    7 

Moisture    3 

100 

1  oz.  by  weight  =127  calories. 

8  level  tablespoonfuls    (levelled  with  a  knife )="!  oz.  by  weight. 
1  level   tablespoonful    (levelled  with  knife)  =16  calories. 


- 

DRY  MILK  301 

to  eight  by  weight  (one  level  tablespoonful  to  one  ounce 
of  water) ,  gives  a  mixture  containing  about  five  and  one-half 
per  cent,  lactose,  one  and  one-half  per  cent,  fat  and  a  little 
over  four  per  cent,  protein.  This  high  protein  content  makes 
it  advisable  to  add  sugar  or  gruels  or  both  to  the  feedings 
of  older  infants  after  the  digestive  disturbances  have  been 
controlled,  but  usually  not  until  four  or  five  ounces  (30  to  40 
tablespoonfuls)  of  the  dry  milk  product  are  consumed  daily. 
With  the  larger  quantities  of  dry  milk  the  urine  is  apt  to 
become  ammoniacal  and  by  increasing  the  calories  with 
starch  and  sugar  this  excessive  ammonia  output  in  the  urine 
can  be  avoided. 

Leaving  aside  the  question  of  digestibility  of  dry  milk, 
there  are  many  distinct  advantages  of  milk  sold  in  this  form. 
The  lessening  of  the  bulk  by  the  removal  of  water  makes  it 
easier  and  cheaper  for  transportation.  When  properly  pre- 
pared it  is  sterile  and  is  therefore  not  a  source  of  disease. 
It  will  keep  without  even  any  changes  in  the  butter  fat  for  a 
period  of  at  least  a  year.  After  the  can  has  once  been  opened 
it  does  not  spoil  and  it  is  not  easily  contaminated,  as,  for 
instance,  is  condensed  milk. 

The  simplicity  of  its  preparation  for  feeding  purposes  by 
simply  adding  the  dry  milk  powder  to  hot  water  is  a  distinct 
advantage  and  therefore  makes  it  available  for  the  masses, 
and  superior  for  the  ignorant  and  uncleanly.  And  finally, 
where  good  milk  is  not  available,  as,  for  instance,  in  the 
smaller  cities  and  towns  where  the  gospel  of  certified  milk 
has  not  penetrated,  or  in  countries  where  climate  or  other 
conditions  prevent  proper  dairying,  or  in  times  of  war,  it 
might  be  considered  almost  invaluable. 

Dry  milk  is  not  a  panacea,  for  there  never  will  be  such 
a  thing  as  a  panacea  in  infant  feeding.  It  is  only  one  more 
weapon  with  which  to  combat  digestive  disturbances,  one 
more  resource  at  hand  to  use  with  infants  of  feeble  digestion 
and  to  tide  over  a  critical  period  in  selected  cases. 


nO  EU 

:McVKS 


CHAPTER  XXIV 

MALT  SOUP  MIXTURES 

MALT  soup  after  Dr.  Keller's  formula  consists  of  a  malt 
extract  which,  becoming  acid  during  the  process  of  manu- 
facture, is  neutralized  with  four  per  cent,  of  potassium  car- 
bonate. To  make  the  food,  the  malt  extract  is  added  to  a 
mixture  of  wheat  flour,  milk  and  water  and  slowly  brought 
to  a  boil. 

Although  many  explanations  have  been  offered  for  the 
efficacy  of  this  food  in  certain  cases,  none  is  entirely  satis- 
factory. Keller,  himself,  attributes  the  good  results  ob- 
tained to  the  large  amount  of  carbohydrate,  which  he  believes 
prevents  putrefaction.  The  boiling  of  the  milk,  the  addi- 
tion of  so  large  a  quantity  of  salts  (potassium  carbonate), 
and,  finally,  its  high  food  value  (caloric  value)  undoubtedly 
all  play  a  part.  Whatever  the  theoretical  explanation,  it  re- 
mains a  fact  that  satisfactory  results  are  obtained  in  a 
certain  class  of  cases.  The  baby  who  under  intelligent  treat- 
ment has  resisted  every  effort  to  make  him  gain  continuously 
in  weight  will  often,  when  put  upon  this  food,  make  a  gain 
of  one-half  pound  the  first  week  and  thrive  as  long  as  the 
food  is  continued. 

This  food  should  be  prepared  in  the  following  manner : 
To  the  proper  amount  of  cold  milk  is  added  an  amount  of 
wheat  flour  which  varies  with  the  individual  infant  (Solu- 
tion No.  1).  To  the  proper  amount  of  hot  water  is  added 
the  malt  soup  extract  (Solution  No.  2).  Equal  amounts  in 
bulk  of  flour  and  malt  soup  must  be  used.  The  cold  milk 
and  flour  (Solution  No.  1)  is  put  upon  the  stove  and  the  water 
and  malt  extract  (Solution  No.  2)  is  poured  into  it.  This 
mixture  is  then  slowly  brought  to  a  boil,  taking  about  twenty 
minutes  in  the  process  and  stirring  all  the  while.  When  it 
has  come  to  an  active  boil  the  food  is  done. 

302 


MALT  SOUP  MIXTURES  303 

The  main  point  in  the  use  of  malt  soup  extract  is  that  no 
set  formula  should  be  used.  Keller's  original  receipt  called 
for  the  same  amount  of  milk,  water,  flour,  and  malt  soup 
extract  for  every  infant.  When  used  in  this  way  failure  may 
be  expected  in  a  large  number  of  cases,  as  it  would  not  be 
possible  to  make  one  formula  of  any  food  that  would  apply 
to  every  infant.  It  is  well  to  begin  with  one-third  milk  and 
two-thirds  water  for  very  small  infants,  while  older  infants 
may  be  started  with  half  milk  and  half  water.  When  first 
using  the  food  begin  with  one  level  tablespoonful  (levelled 
with  a  knife)  or  one-quarter  ounce  of  flour  (by  weight)  and 
one  very  scant  tablespoonful  of  malt  soup  extract  (one-half 
ounce  by  weight) .  The  malt  soup  extract  and  flour  should 
later  be  gradually  increased  in  quantity,  a  tablespoonful  at 
a  time,  as  the  infant  needs  more  food  and  as  its  tolerance 
increases.  Care  should  be  taken  to  reckon  the  calories  very 
accurately  in  order  to  make  sure  that  overfeeding  or  under- 
feeding will  not  result.  The  author  has  seldom  found  it 
necessary  to  use  more  than  one  ounce  by  weight  (four  level 
tablespoonfuls)  of  flour  or  two  ounces  by  weight  (four  scant 
tablespoonfuls)  of  malt  soup  extract.1  After  the  proportion 
of  milk  and  water  has  reached  half  and  half,  it  should  be  kept 
at  this  strength  for  a  month  or  two ;  that  is,  if  a  larger  quan- 
tity of  milk  is  needed  to  fulfil  the  infant's  caloric  require- 
ments, an  equal  amount  of  water  is  used.  Later,  when  the 
bulk  becomes  too  great  with  half  milk  and  half  water,  two- 
thirds  milk  or  even  three-quarters  milk  may  be  used. 

Malt  soup  is  fed  at  the  same  intervals  and  in  the  same 
quantities  as  any  other  food.  It  may  be  continuously  used 
for  a  period  of  four  or  five  months  without  causing  anaemia, 
rickets,  or  other  nutritional  disturbances.  The  danger  of 
scurvy  is  obviated  by  giving  orange  juice  after  the  food  has 

1  Two  scant  tablespoonfuls  (one  ounce  by  weight)  of  malt  soup  extract  equal 
90  calories. 

Four  level  tablespoon fute  (one  ounce  by  weight)  of  flour  equal  100  calories. 


304  SIMPLIFIED  INFANT  FEEDING 

been  used  for  two  months,  or  sooner  in  older  infants.  This 
is  a  detail  which  should  not  be  omitted  with  this  food  or  any 
other  food  that  is  boiled. 

The  stools  are  usually  looser  in  consistency  and  more 
numerous  when  the  malt  soup  feeding  is  used,  but  are  other- 
wise normal  in  appearance,  showing  no  signs, of  indigestion, 
and  the  infant  makes  a  continuous  gain  in  weight. 

CASE  LXXVIIl 

(Illustrating  the  use  of  malt  soup  feedings) 
November  30:     Age,  3%  months.     Birth  weight,  11  Ib. 

Present  weight,  10  Ib.  4  oz. 
Loss,  12  oz. 
General  Condition. — Poorly  nourished,  pale,  good  musculature,   no  evidence 

of  rickets.     Needs  55  calories  per  pound  per  day. 

Stools. — For  two  days,  four  watery,  yellow  stools  with  mucus  but  no  curds. 
Vomiting. — Considerable  quantity  after  each  feeding. 
Appetite. — Ravenous. 
Sleep. — Poor ;  crying  night  and  day. 
Temperature,  98°  F. 

Chief  Complaint. — Repeated  attacks  of  diarrhoea. 

Previous  Food  and  Feeding  History. — This  infant  was  first  seen  at  one  month  of 
age.  During  the  first  month  of  life  it  had  been  underfed  on  the  breast  with 
a  loss  of  nearly  three  pounds  (if  the  birth  weight  given  was  correct).  Arti- 
ficial feeding  was  instituted  with  poor  results.  Whole  milk  and  water  was 
instituted  with  a  gradual  addition  of  sugar  until  this  date  (November  30). 
During  this  period  of  two  and  a  half  months  since  last  seen  there  had  been 
a  gain  of  two  pounds,  but  there  had  been  four  attacks  of  diarrhoea  and  vomit- 
ing. Each  time  the  indigestion  was  overcome  by  stopping  the  sugar  and 
giving  milk  and  water  boiled. 

Treatment. — Food  prescribed: 

L  \ 
Water    18  oz.  }  bolll~  each.    Feed  every  3  hours  at 

Sugar    0  6,  9,  12  A.M.,  3,  6,  9  P.M.,  and 

2  A.M. 

360  calories,  or  33  calories  per  pound. 
December  3   (3  days  later) :    Weight,  10  Ib.  4  oz. 

No  eain  or  loss. 

General  Condition. — The  same. 

Stools. — Constipated ;  i.e.,  one  with  enema,  yellow,  hard,  no  mucus  or  curds. 
Vomiting. — Very  little. 
Appetite. — Hungry. 


Milk    18  oz.  )  (360  cals.)       Divide  into  7  bottles  of  5+  oz. 

boiled 


MALT  SOUP  MIXTURES  305 

Treatment. — Food  prescribed: 

Milk 20  oz.  I  400  cals.  Divide  into  7  bottles.    Feed  6— 

Water    20  oz.  J  oz.  every  3  hours  at  6,  9,  12 

Malt  soup %  oz.  ( 1  tbsp.)   45  cals.        A.M.,  3,  6,  9  P.M.,  and  2  A.M. 

Flour   y4  oz.  ( 1  tbsp.)   25  cals. 

470  cals.,  or  46-  per  pound. 

December  8   (5  days  later)  :     Weight,  10  Ib.  9  oe. 

Gain,  5  oz. 

General  Condition. — Improved. 
Stools. — Two  normal. 
Vomiting. — None. 
Appetite. — Ravenous. 
Sleep. — Poorj  cries  before  feedings  from  hunger. 

Treatment. — Food  prescribed : 

Milk 20  oz. )  400  cals.     Divide  and  feed  as  before. 

Water    20  oz.  \  ^^ 

Malt  soup 1  oz.  ( 2  tbsp. )    90  cals. 

Flour %  oz. (2  tbsp. )    50  cals. 

540  cals.,  or  54-  cals.  per  pound. 

December  18  (10  days  later)  :    Weight,  11  Ib.  2  oz. 

Gain,  9  oz. 

General  Condition. — Improved,  with  gain  in  weight. 
Stools. — Two  normal. 
Vomitin  g. — None. 
A  ppetite. — Hungry. 
Sleep. — Good. 

Treatment. — Food  prescribed: 

Milk    20  oz.  )  400  cals.  Diyide  and  feed  ac  before. 

Water    20  oz.  f 

Malt  soup 1%  oz.  (3  tbsp.)  135  cala. 

Flour   %  oz.  (3  tbsp.)  75  cals. 

610  cals.,  or  55-  calories  per  pound. 

This  baby  was  fed  upon  malt  soup  for  the  next  five  months  without  any 
recurrence  of  the  diarrhoea,  and  during  that  time  gained  nine  pounds,  nearly 
doiibling  its  weight.  (Weight,  April  30,  19  pounds.)  There  were  no  evidences 
of  rickets,  ansemia  or  scurvy  at  any  time.  The  juice  of  half  an  orange  was 
given  twice  a  day  after  the  infant  had  received  the  malt  soup  for  two  months. 

20 


306 

This  was  a  difficult  and  discouraging  feeding  case  until 
the  malt  soup  was  used.  Although  carefully  fed  with 
milk,  water  and  sugar  mixtures  and  doing  nicely  upon  them 
for  a  week  or  two,  without  any  apparent  cause  and  often 
without  any  change  of  food  at  the  time,  the  infant  would 
suddenly  develop  diarrhoea  and  vomiting  and  cry  day  and 
night  from  indigestion.  The  sugar  taken  from  the  food, 
the  digestive  disturbances  would  stop.  Added  again,  one 
teaspoonful  at  a  time,  up  to  an  ounce  in  the  twenty-four- 
hour  amount,  the  infant  would  gain  weight  for  a  week  or  so, 
when  the  same  thing  would  occur  again.  Different  kinds 
of  sugar  were  tried,  and  even  milk  in  sufficient  quantities 
without  any  sugar,  but  without  avail.  The  malt  soup  was 
begun,  followed  by  an  immediate  and  continuous  improve- 
ment. This  is  only  one  of  a  series  of  such  cases. 

It  is  sometimes  advisable  to  start  with  far  smaller  quan- 
tities of  malt  soup  and  flour  than  given  in  the  last  case.  A 
very  small,  emaciated  infant  who  has  had  a  great  deal  of 
diarrhoea  and  who  has  never  done  well  on  any  food  will  not 
digest  even  a  tablespoonful  each  of  malt  soup  and  flour  at 
first.  By  beginning  with  a  teaspoonful  of  each  the  tolerance 
is  gradually  increased  for  larger  amounts. 

CASE  LXXIX 
(Illustrating  the  use  of  malt  soup  mixtures) 

September  16:     Age,  5  months:     Birth  weight,  8%  lb.(?) 

Present  weight,  6  Ib.  10  oz. 

General  Condition. — Extremely  emaciated,  undersized,  pale,  skin  rough,  dry 
and  scaly  with  eczematous  spots.  Mouth  and  tongue  red.  Umbilical  hernia. 
Abdominal  distention.  Needs  from  60  to  65  calories  per  pound  per  day. 

Stools. — For  two  weeks,  three  or  four  green  or  yellow,  loose,  watery  stools  with 
mucus. 

Vomiting. — A  considerable  quantity  immediately  after  each  feeding. 

Appetite. — Good;  takes  all  the  food. 

Sleep. — Restless. 

Temperature,  97°  F. 

Chief  Complaint. — Repeated  attacks  of  diarrhoea;  has  never  gained  in  weight. 


MALT  SOUP  MIXTURES  307 

Previous  Food. — Breast-fed  for  three  weeks.  Was  then  fed  plain  milk,  water 
and  dextri-maltose  mixtures  in  varying  dilutions  and  quantities  until  two 
weeks  ago. 

Milk 14  oz.  |  Fed  4  oz.   every   2%   hours,  7   or   8 

Water    17  oz.  j  feedings  in  24  hours. 

Dextri-inaltose  ...      1  oz. 

For  the  last  two  weeks  has  had  a  feeding  made  with  two  tablespoonfuls 
of  barley  flour  and  two  teaspoonfuls  of  malt  soup  extract  to  one  quart  of  water. 
Treatment. — Food  prescribed: 

Milk 10  oz.  "i  Divide  into  10  feedings  of  3  oz.  each. 

Water    20  oz.\  Feed  every  2  hours  at  6,  8,  10,  12 

Sugar 0  oz.  A.M.,  2,  4,  6,  8,  10  P.M.,  and  2  A.M. 

Increase  the  milk  one  ounce  each  day,  decreasing  the  water  an  equal 
amount  until  the  proportion  is  half  and  half. 

September  21   (5  days  later)  :    Weight,  6  Ib.  10  oz. 

No  gain  or  loss. 

General  Condition. — As  at  the  last  visit. 
Stools. — One  smooth,  homogeneous,  normal  stool. 
Vomiting. — Practically  none    (a  mouthful  now  and  then). 
Sleep. — Good  at  night,  poor  during  the  day. 
A  ppeti  te. — Ravenous. 
Temperature,  97°  F. 
Treatment. — Food  prescribed : 

Milk    16  oz.  |       .  Divide  into  10  bottles.     Feed  3 

Water 16  oz.  \  boiled  oz.  every  2  hours,  at  6,  8,  10, 

Malt  soup  ....      1  teaspoonful   (%  °z-)  12  A.M.,  2,  4,  6,  8,   10  P.M., 

Wheat  flour  ...      1  teaspoonful   ( y8  oz. )  and  2  A.M. 

Increase  the  malt  soup  and  flour  a  teaspoonful  each  day. 

September  24  (3  days  later)  :    Weight,  6  Ib.  13  oz. 

Gain,  3  oz. 

General  Condition. — Somewhat  improved. 
Ktools. — One  normal. 
Tomiting. — None. 
Sleep. — Good  at  night. 
Appetite. — Hungry. 
Temperature,  98°  F. 
Treatment. — Food  prescribed : 

Milk 16  oz.    )       .  320  cals.     Divide  into  10  feedings  and 

Water    16  oz.    f  feed  as  before. 

Malt  soup  . .  1  tablespoonful   ( y2  oz. )   45  cals. 
Flour    1  tablespoonful   ( ^4  oz. )   25  cals. 

300  cals.,  or  58-  calories  per  pound. 


SIMPLIFIED  INFANT  FEEDING 


October  7  (2  weeks  later) 


General  Condition  —  Improved. 
Stools.  —  One  normal. 
Vomiting.  —  None. 
Sleep.  —  Excellent. 
Appetite.  —  Hungry. 

Treatment.  —  Food  prescribed  : 
Milk  .......  16  oz.  ) 

Water   .....  16  oz.  [  b 

Malt    soup.     2  tablespoonfuls  (1 
Flour     ____     2  tablespoonfuls  ( 


Weight,  7  Ib.  13  oz. 
Gain,  1  Ib. 


320  cals.    Divide     into     7     bottles. 
Feed    4%     oz.  every    3 
oz.)  90  cals.        hours  at  6,  9,  12  A.M.,  3, 
oz.)  50  cals.         6,  9,  P.M.,  and  2  A.M. 

460  cals.,  or  59+  calories  per  pound. 


October  21   (2  weeks  later)  :  Weight,  9  Ib.  2  oz. 

Gain,  1  Ib.  5  oz. 

General  Condition.  —  Much  improved. 
Stools.  —  Two  normal  every  day. 
Vomiting.  —  None, 
Sleep.  —  Good. 
Appetite.  —  Satisfied. 

Treatment.  —  Food  prescribed: 

Milk  .......  16  oz.  1  320  cals. 

Water   .....  16  oz.  }  b 

Malt   soup.     3  tablespoonfuls  (1%  oz.)135  cals. 
Flour     ....     3  tablespoonfula  (  %  oz.)  75  cals. 


Divide  into  7  bottles.  Fe«d 
5  oz.  every  3  hours  at  6, 
9,  12  A.M.,  3,  6,  9  P.M., 
and  2  A.M. 


530  cals.,  or  59-  cals.  per  poumd. 


CHAPTER  XXV 
SALTS  OF  MILK 

A.   W.   BOSWOBTH   AND   H.    I.   BOWDITCH,  M.D. 

(The   Boston  Floating  Hospital  Laboratories) 

Cow's  milk,  nature's  food  for  the  offspring  of  the  cow, 
contains  inorganic  constituents  in  sufficient  amounts  to 
supply  the  demands  of  the  rapid  growth  and  development  of 
this  animal  and  is  especially  rich  in  calcium  and  phosphorus, 
substances  which  the  young  of  the  cow  use,  to  develop  a 
rapidly  growing  bone  tissue,  but  which  the  infant  uses  very 
sparingly.  When  fed  to  infants  in  the  proportions  found 
in  cow's  milk  or  modified  milk,  these  substances  are  greatly 
in  excess  of  the  amounts  required  to  supply  the  demands 
of  the  infant  and  this  excess  must  be  eliminated  either  in 
the  urine  or  the  faeces. 

In  this  connection  it  is  a  noteworthy  fact  that  notwith- 
standing the  high  calcium  content  of  cow's  milk  the  calcium 
metabolism  of  bottle-fed  infants,  as  measured  by  the  calcium 
eliminated  in  the  urine,  is  seldom  greater,  and  often  less, 
than  found  in  the  breast-fed  infants,  most  of  the  calcium 
being  eliminated  in  the  faeces  as  insoluble  calcium  phosphate 
and  calcium  soaps.  While  this  mode  of  eliminating  the 
excess  calcium  present  in  cow's  milk  is  in  one  way  a  pro- 
tection to  the  infant,  in  that  it  prevents  the  calcium  from 
entering  the  body  fluids  and  tissues  in  organic  combinations, 
subsequently  to  set  up  a  toxic  condition,  it  may,  on  the  other 
hand,  bring  about  nutritional  disturbances. 

If  we  take  into  consideration  the  excess  01  calcium  and 
phosphorus  and  so  modify  cow's  milk  as  to  reduce  these  sub- 
stances to  the  amounts  required  by  the  infant,  the  ordinary 
top  milk  mixtures  with  high  fats  and  comparatively  low 
proteids  will  deprive  the  infants  of  the  required  amounts  of 
other  mineral  elements. 

This  phase  of  the  feeding  problem  demands  more  consid- 
eration than  has  been  given  to  it  in  the  past  and  more  care 

309 


310 


SIMPLIFIED  INFANT  FEEDING 


must  be  taken  to  see  that  the  mineral  elements  are  prop- 
erly balanced. 

It  has  been  the  general  practice  to  consider  the  quantity 
of  mineral  elements  present  in  milk  to  be  represented  by 
the  ash,  and  figures  obtained  by  the  analysis  of  such  an 
ash  have  been  quite  generally  accepted.  Such  an  analysis 
does  not,  however,  represent  the  true  mineral  content  of 
milk,  for  under  the  conditions  ordinarily  surrounding  the 
determination  of  ash,  some  of  the  sulphur  and  phosphorus 
in  the  protein  molecule  will  be  lost  by  volatilization.  If  this 

TABLE  I 
MINERAL  ELEMENTS  IN  MILK  AND  MILK  ASH 


Cow's  milk 

Human  milk 

Sulphur  trioxide  (SOs)  

In  ash  from 
100  c.c. 
milk 
Gm. 

0.025 

0.199 
0.076 
0.201 
0.022 
0.145 
0.074 

In  100 
c.c.  milk 

Gm. 
0.054 
0.249 
0.076 
0.201 
0.022 
0.145 
0.074 

In  ash  from 
100  c.c. 
milk 
Gm. 

0.002 

0.034 
0.038 
0.050 
0.005 
0.086 
0.020 

In  100 
o.c.  milk 

Gm. 
0.004 
0.036 
0.038 
0.050 
0.005 
0.086 
0.020 

Phosphorus  pentoxide  (P2O6)  

Chlorine  (Cl)  

Calcium  oxide  (CaO)  

Magnesium  oxide  (MgO)  

Potassium  oxide  (KoO)  

Sodium  oxide  (NajO)  

Oxygen  equivalent  to  chlorine  .... 

0.742 
0.017 

0.821 
0.017 

0.235 
0.008 

0.239 
0.008 

Totals.. 

0.725 

0.804 

0.227 

0.231 

loss  is  taken  into  consideration,  the  true  mineral  content  of 
milk  will  be  found  to  be  quite  different  from  that  repre- 
sented by  the  ash.  This  point  is  brought  out  by  the  figures 
given  in  Table  I,  which  were  obtained  from  milks  of  average 
composition  by  Van  Slyke  and  Bosworth  in  the  case  of  the 
cow's  milk  and  by  Bosworth  for  human  milk.  Cow's  milk, 
giving  a  total  ash  amounting  to  0.725  per  cent.,  will  be  seen 
to  really  contain  mineral  elements  to  the  extent  of  0.804 
per  cent.,  while  human  milk,  giving  a  total  ash  amounting 
to  0.227  per  cent.,  will  be  seen  to  contain  mineral  elements 
to  the  extent  of  0.231  per  cent. 

It  is  known  that  bottle-fed  infants  absorb  and  retain  a 
much  smaller  percentage  of  the  mineral  elements  ingested 


SALTS  OF  MILK  311 

than  is  the  case  with  breast-fed  infants,  and  this  has  been 
considered  due  to  the  fact  that  bottle-fed  infants  receive 
an  excess  of  mineral  elements  and  necessarily  must  excrete 
greater  amounts.  While  this  is  in  part  true,  it  should  be 
pointed  out  that  recent  investigations  by  Bowditch  and 
Bosworth  have  shown  that  all  the  mineral  constituents  pres- 
ent in  cow's  milk  are  not  available  to  the  infant  as  a  food 
and  are  eliminated  in  the  faeces.  These  investigations  have 
shown  that  di-calcium  phosphate,  which  salt  Bosworth  has 
shown  to  be  a  normal  constituent  of  cow's  milk  but  to  be 
absent  in  human  milk,  is  inert  in  so  far  as  its  food  value 
is  concerned. 

It  will  be  seen,  therefore,  that  the  consideration  of  the 
forms  in  which  the  mineral  elements  are  present  is  an  im- 
portant factor  and  that  in  calculating  the  amount  of  mineral 
elements  present  and  available  in  modified  cow's  milk  as 
used  for  infant  feeding  the  di-calcium  phosphate  present 
should  be  considered  unavailable  and  a  corresponding  de- 
duction made  from  the  total  mineral  elements  in  this  milk. 

In  this  connection  it  should  be  stated  that  Bosworth  has 
shown  how  the  addition  of  lime  water  to  milk  brings  about 
a  precipitation  of  calcium  phosphate  and  thereby  reduces 
the  amounts  of  available  calcium  and  phosphorus  in  the 
milk.  It  is  also  known  that  boiling  milk  causes  a  precipita- 
tion of  some  of  the  soluble  and  available  calcium. 

The  incineration  of  milk  leaves  an  ash  in  which  the 
arrangement  of  the  elements  is  altogether  different  from 
that  in  which  they  were  present  in  the  original  milk.  The 
following  statement  (Table  II)  of  the  forms  in  which  the 
mineral  elements  are  present  in  milk  is  given  as  the  result 
of  extended  studies  of  the  chemistry  of  milk  by  Bosworth. 

In  most,  if  not  all,  of  the  methods  for  modifying  cow's 
milk  the  mineral  elements  present  receive  very  little  con- 
sideration, being  passed  over  with  the  statements  that  modi- 
fied cow's  milk  will  always  contain  a  larger  percentage  of 
ash  than  breast  milk  and  therefore  much  more  salt  will  be 
given  to  infants  receiving  modified  milk  than  they  require. 


312 


SIMPLIFIED  INFANT  FEEDING 


From  the  data  presented  here  it  will  be  seen  that  this  is  an 
erroneous  stand  to  take,  for  the  ash  constituents  cannot  be 
considered  as  a  group,  but  must  be  considered  individually. 
This  is  distinctly  shown  by  the  figures  for  a  formula  con- 
taining 1  per  cent,  protein.  In  this  case  the  food  will  contain 
a  total  ash  of  0.25  per  cent,  and  an  available  ash  of  0.20  per 
cent.,  compared  with  a  total  and  available  ash  of  0.23  per 

TABLE  II 
FORMS  IN  WHICH  THE  MINERAL  ELEMENTS  ARE  PRESENT  IN  MILK 


In  100  c.c. 
cow's  milk 
Gm. 

In  100  c.c. 
human 
milk 
Gm. 

Sulphur  within  the  casein  and  albumin  

0.022 

0.001 

Phosphorus  within  the  casein  

0.022 

0.001 

Salt  Combinations 
Calcium  combined  with  the  protein  

0.054 

0.024 

Di-calcium  phosphate  (CaHPO*  

0.175 

0.000 

Mono-magnesium  phosphate  (MgH^P^Og  

0.103 

0.027 

Di-potassium  phosphate  (KjHPO*)  

0.230 

0.000 

Mono-potassium  phosphate  (KHzPO*)  

0.000 

0.069 

Potassium  citrate  (CgHsOrKj)  

0.052 

0.103 

Sodium  citrate  (CjH&OrNaa)  

0.222 

0.055 

Calcium  chloride  (CaCk)  

0.119 

0.059 

Iron  

Trace 

Trace 

Total  Salts  

0.955 

0.337 

cent,  in  breast  milk,  a  chlorine  content  of  0.024  per  cent.,  com- 
pared with  0.038  per  cent,  in  breast  milk,  and  a  potassium 
oxide  content  of  0.045  per  cent.,  compared  with  0.086  per 
cent,  in  breast  milk.  A  child  receiving  a  formula  with  this 
percentage  of  protein  is  taking  a  total  ash  greater  than  that 
found  in  breast  milk,  but  is  being  underfed  with  respect  to 
chlorine  and  potassium  if  the  chlorine  and  potassium  con- 
tent of  breast  milk  is  taken  as  a  standard. 

As  the  amounts  of  mineral  elements  in  any  modified 
milk  will  depend  upon  the  quantities  of  whole  milk  or 
skimmed  milk  and  cream  used  to  give  the  desired  percentage 
of  protein  it  is  very  easy  to  calculate  from  the  protein 
content  the  amounts  of  available  mineral  elements  pres- 
ent in  any  formula.  The  results  obtained  in  this  way  are 
given  in  Table  III.  In  consulting  these  figures  it  should  be 


313 


understood  that  they  are  average  figures  from  milks  of 
average  composition. 

Taking  breast  milk  as  the  standard,  an  examination  of 
the  figures  in  Table  III  shows  that  all  modifications,  made 
by  the  use  of  cream  and  whole  milk  or  skimmed  milk  without 
the  addition  of  lime  water,  which  contain  less  than  2  per 
cent,  protein,  are  deficient  with  respect  to  chlorine  and 

TABLE  III 

AVAILABLE     MINERAL     ELEMENTS     IN     DIFFERENT     MODIFIED     COW'S     MILK     FOR- 
MULAE A8  COMPARED  TO   THOSE   IN  BREAST  MILK.     WHOLE  MILK  OR  SKIMMED  MILK 

AND  CREAM  USED 


Protein 

No  Kme  water  added: 

Ash 

Sulphur  trioxide  (SOi) 

Phosphorus  pentoxide  (PzOs) .  . . 

Chlorine  (CD 

Calcium  oxide  (CaO) 

Magnesium  oxide  (MgO) 

Potassium  oxide  (KsO) 

Sodium  oxide  (NaaO) 


Lime  water  added  equal  to  25  per  cent, 
of  the  milk  and  cream  used: 

Ash 

Sulphur  trioxide  (SOa) 
Phosphorus  pentoxide 
Chlorine  (CD 
Calcium  oxide  (CaO) 
Magnesium  oxide  (MgO) 
Potassium  oxide  (KiO) 
Sodium  oxide  (NaaO) 


Lime  water  added  equal  to  50  per  cent. 
of  the  milk  and  cream  used: 

Ash 

Sulphur  trioxide  (SOs) 

Phosphorus  pentoxide  (PiOs) 

Chlorine  (Cl) 

Calcium  oxide  (CaO) 

Magnesium  oxide  (MgO) 

Potassium  oxide  (KiO) 

Sodium  oxide  (NaiO) 


0.75 


.042 


0.1330 
0.0130 
0.0230 
0.0180 
0.0280 
0.0050 
0.0340 
0.0170 


0.1280 
0.0130 
0.0170 
0.0180 
0.027 


0.005 
0.034 
0.017 


1.00 


1780 
0170 
0300 
0240 
0370 
0070 
0450 
0230 


.1700 
.0170 
.0230 
.0240 
.0370 
.0070 
.0450 
.0230 


1.25 


2220 
0210 
0370 
0300 
0460 
0090 
0560 


1.50 


02 

04 

0360 

0560 

0100 

0680 


.2550.298 
025  0 .030 


1.03; 


0.040 


2130 
0210 
0290 
0300 
0460 
0090 
0560 
0290.0350.040 


1.75 


2.00 


2670 
0 
0.0530 


.3110 
.0300 


.042 
.06J 
.0120 
0790 


.036  0.042 
0560.064 
0100.012 
068  0.079 


2.25 


3560 
0340 
0600 
0480 
0740 
0140 
0900 


029  0  .035  0  .040  0  .046  0 .052  0 .058  0  020 


2.50 


Jreast 

Milk 


5000.231 


.1240.036 


.060 


0.038 
0.050 
0.005 
0.086 


.0580.020 


.445 


4000. 

0380. 

0680. 

0530. 

0840.0930.050 

0150. 

1020. 


i.04: 
1.07; 
.060 


.01 
.113 


0.004 


0.231 


0.004 
0.036 
0.038 


0.005 
0.086 


potassium  and  that  all  modifications  containing  more  than 
1.25  per  cent,  protein  have  an  excess  of  available  calcium. 
By  the  addition  of  25  to  50  per  cent,  of  lime  water  to  the 
milk  and  cream  some  of  the  excess  calcium  is  precipitated 
as  unavailable  calcium  phosphate,  and  formulae  containing 
over  1.50  per  cent,  of  protein  have  an  excess  of  available 
calcium.  The  overfeeding  of  available  calcium  is  to  be 
guarded  against  because  it  results  in  the  appearance  of 
calcium  soaps  in  the  stools  and  these  soaps  may  be  the  cause 
of  excessive  constipation. 


314  SIMPLIFIED  INFANT  FEEDING 

As  far  as  the  mineral  elements  are  concerned,  therefore, 
the  question  as  to  which  modification  of  whole  milk  or 
skimmed  milk  and  cream  to  feed  seems  to  resolve  into  an 
effort  to  bring  the  protein  content  as  near  2  per  cent,  as 
possible  in  order  to  feed  the  proper  amounts  of  chlorine 
and  potassium  and  to  reduce  the  available  calcium  to  a  point 
where  excessive  soap  formation  will  be  avoided.  A  formula 
containing  between  1.75  per  cent,  and  2  per  cent,  protein 
would  seem  to  be  the  most  desirable  one  and  the  one  to  be  fed 
as  soon  as  possible  under  ordinary  conditions. 

"With  reference  to  the  salts  in  boiled  milk,  it  can  only  be 
said  that  no  good  work  of  sufficient  amplitude  has  been  done 
upon  the  subject  to  warrant  much  of  a  statement.  It  is 
known,  however,  that  boiling  milk  causes  a  precipitation 
of  some  of  the  soluble  and  available  calcium.  This  is  very 
desirable  from  two  standpoints:  First,  because  in  the  re- 
duction of  soluble  calcium  the  possibility  of  calcium  soap 
formation  is  reduced  and  this,  in  turn,  has  some  tendency 
to  reduce  constipation.  Second,  because  the  precipitation 
of  some  of  the  soluble  calcium  salts  changes  the  nature  of 
the  curd  formed  in  the  stomach,  a  much  softer  and  finer  curd 
being  formed  by  boiled  milk. 

AUTHOK'S  NOTE 

Work  is  now  being  undertaken  to  determine  the  exact 
change  which  takes  place  in  the  salts  of  milk  in  the  boiled 
milk  formulae.  From  a  clinical  standpoint,  it  would  seem 
that  the  excess  of  calcium  was  all  taken  care  of  in  the  boil- 
ing process,  since  constipation  is  very  unusual  and  soapy 
stools  rarely  occur.  The  strong  mixtures  of  milk  and  water, 
which  the  author  recommends  throughout  this  book,  give 
a  percentage  of  l1/^  to  2  per  cent,  of  protein  and  supply, 
therefore,  the  adequate  quantity  of  potassium  salts  and 
chlorine.  It  will  be  seen  that,  throughout  the  book,  mix- 
tures that  are  weaker  than  one-half  milk  and  one-half  water 
are  never  recommended,  except  as  a  temporary  measure. 

It  is  to  be  hoped  that  these  clinical  observations,  there- 
fore,- will  soon  be  verified  by  careful  laboratory  research. 


CHAPTER  XXVI 

BOTTLE  WEANING  AND  FOOD  FOR  OLDER 
CHILDREN 

PROBABLY  half  the  children  between  the  ages  of  one  and 
five  years  that  come  to  the  physician  for  treatment  have  the 
diet  to  account  for  their  condition.  During  the  second  year 
when  the  children  are  changing  from  a  period  of  infancy  to 
that  of  young  adult  life,  the  subject  of  diet  is  of  the  utmost 
importance.  Medical  literature  abounds  in  articles  upon 
the  feeding  of  infants  during  their  first  year,  perhaps  be- 
cause the  theories  of  infant  feeding  are  varied  and  not  as 
yet  thoroughly  settled,  but  little  is  said  about  the  diet  of 
children  during  their  second  and  third  years.  During  the 
early  part  of  the  second  year,  children,  if  allowed  to  do  so, 
will  either  eat  nothing  at  all  in  the  way  of  solid  food  or  will 
eat  too  much  solid  food  if  allowed  to  follow  their  own  inclina- 
tions. 

One  of  the  chief  errors  which  the  author  believes  is  com- 
monly made  is  the  practice  of  feeding  too  frequently  during 
the  second  year.  Many  authorities  recommend  at  least  five 
or  six  meals  at  this  age,  and  this  is  undoubtedly  a  great  mis- 
take. As  soon  as  children  have  become  old  enough  to  take 
solid  food  they  are  often  fed  too  frequently,  and  too  frequent 
feedings  cause  digestive  disturbances  and  loss  of  appetite, 
and,  consequently,  poor  nutrition  and  anemia  result.  They 
will  take  only  part  of  the  food  offered  and  included  in  their 
dietaries,  and  they  never  seem  to  be  hungry  enough  to  take 
any  new  articles  of  food.  This  is  a  very  unfortunate  situa- 
tion, because  during  the  second  year  it  is  necessary  to  intro- 
duce into  the  dietary  one  new  food  after  another,  which  from 
a  practical  standpoint  is  impossible  when  the  child  is  not 

315 


316  SIMPLIFIED  INFANT  FEEDING 

hungry  enough  to  eat.  After  the  fourteenth  month,  the 
proper  procedure  is  to  cut  down  the  number  of  meals  to 
three  with  the  addition  of  a  10  P.M.  bottle.  At  eighteen 
months  this  10  P.M.  feeding  should  be  omitted. 

The  older  children  should  have  their  meals  as  regularly 
as  infants  have  their  feedings  and  not  be  allowed  to  eat  be- 
tween meals.  No  child  should  have  set  before  it  things 
which  it  may  not  eat.  The  usual  family  breakfast  and 
luncheon  are  meals  such  as  the  children  may  be  permitted 
to  share,  but  they  should  never  be  allowed  to  eat  with  the 
family  at  dinner  time.  It  is  a  good  plan  to  give  them  their 
supper  in  the  nursery  at  5  or  5.30  o  'clock  so  that  they  may 
be  in  bed  during  the  family  dinner  hour. 

One  of  the  most  frequent  errors  in  diet  is  that  of  allowing 
too  much  milk  during  this  period.  Milk  is  a  very  good 
article  of  food  for  children  and  they  should  be  allowed  to 
have  a  certain  amount  of  it  each  day.  After  eighteen  months 
of  age,  one  milk  meal  a  day  is  enough.  Too  much  milk  has 
the  same  effect  as  too  frequent  feedings  and  is  also  the  most 
frequent  of  all  the  causes  of  constipation.  It  is  not  uncom- 
mon to  see  a  child  of  one  and  one-half  years  of  age  getting 
two  quarts  of  milk  in  twenty-four  hours.  In  older  children 
it  is  often  given  to  them  with  each  meal ;  in  younger  children 
a  drink  of  milk  is  given  as  a  beverage  whenever  they  become 
thirsty  and  they  are  allowed  to  partake  of  it  instead  of  water. 
This  is  ruinous  to  their  digestion. 

The  use  of  cereals  is  almost  invariably  overdone  at  this 
age.  It  is  a  common  custom  to  give  cereals  twice  a  day,  and 
some  children  get  them  oftener  than  this.  One  cereal  meal  a 
day  is  enough  at  any  age,  but  it  is  particularly  important  that 
no  more  than  this  should  be  given  after  the  teeth  have  come. 
One  reason  why  so  many  American  children  have  teeth  that 
are  not  well  formed  and  decay  early  is  that  they  are  not 
given  enough  solid  food  upon  which  to  chew.  Unfortunately, 
the  eating  of  mushy  foods  exclusively  is  the  rule  throughout 


BOTTLE  WEANING  317 

childhood.  Children  get  into  the  habit  of  eating  without 
masticating  the  food  thoroughly,  since  such  food  can  be 
swallowed  without  any  chewing,  and  in  this  way,  in  part  at 
least,  the  American  habit  of  rapid  eating  is  acquired.  This 
is  one  of  the  reasons  why  all  bread  should  be  put  into  the 
oven  and  thoroughly  dried  until  it  is  hard.  It  should  then  be 
chewed  without  the  aid  of  liquids  to  wash  it  down. 

New  foods  are  being  constantly  introduced  into  the  diet 
during  the  second  year.  It  is  advisable  to  begin  with  small 
quantities  of  a  new  food  and  gradually  increase  the  amount. 
If  a  food  seems  to  disagree  with  a  child,  it  should  not  be 
eliminated  from  the  diet  but  repeatedly  tried  in  small  quanti- 
ties until  it  is  properly  assimilated,  provided  that  the  food 
is  a  proper  one. 

Getting  the  child  to  take  the  diet  prescribed  is  one  of 
the  first  difficulties  that  is  encountered,  as  there  are  so  many 
children  who  with  great  difficulty  learn  to  eat  solid  food  at 
the  beginning  of  the  weaning  period.  This  is  usually  due  to 
two  mistakes.  The  first  one  of  these  is  in  not  beginning  to 
feed  the  baby  with  the  spoon  early  enough.  At  eight  or  nine 
months  of  age  all  children  should  learn  to  take  water,  milk 
or  small  amounts  of  cereal  from  the  cup  or  spoon,  so  that 
they  may  learn  to  eat  and  thus  acquire  a  taste  for  food. 
Some  children  always  seem  to  have  a  distaste  for  any  new 
article  of  food,  and  the  matter  of  discipline  enters  into  their 
taking  the  diet  that  is  prescribed,  since  they  must  be  taught 
to  acquire  a  taste  for  each  new  food.  There  are,  of  course, 
those  children  who  want  to  eat  everything  that  the  adult 
eats,  and  are  allowed  to  do  so,  but  a  discussion  of  such  cases 
need  not  be  included  here. 

In  laying  out  a  diet  for  a  child,  it  is  never  sufficient  to 
say  that  it  may  take  this  and  may  not  take  that,  but  each 
meal  should  be  planned.  After  inquiring  into  the  habits  of 
the  family  and  the  time  of  the  child's  sleeping  periods,  the 
time  of  day  for  the  meals  should  be  definitely  stated.  A  very 


318 

general  error  in  prescribing  a  diet  both  in  sickness  and  in 
health  is  to  say  what  the  patient  should  not  eat,  without 
giving  something  to  take  the  place  of  the  food  which  has 
been  interdicted. 

Bottle  Weaning  at  Eight  to  Ten  Months  of  Age. — Weaning 
from  the  bottle  should  always  be  gradual  if  it  is  begun 
between  the  eighth  and  twelfth  months.  This  is  the  proper 
age  to  begin  to  wean  a  well-nourished,  normal  infant.  Babies 
who  are  very  much  undersized  and  who  are  poorly  nourished 
or  have  had  a  stormy  career  so  far  as  bottle  feeding  is  con- 
cerned, often  cannot  be  weaned  until  the  beginning  of  the 
second  year. 

At  eight  months  of  age  the  strength  of  the  mixture  should 
be  rapidly  increased  from  two-thirds  milk  to  three-fourths, 
then  to  four-fifths  milk,  so  that,  by  the  time  the  infant  is  nine 
or  ten  months  of  age,  undiluted  milk  may  be  given  in  the 
bottle.  In  the  meantime  the  sugar  should  be  gradually 
decreased  so  that  it  is  entirely  omitted  as  soon  as  the  un- 
diluted milk  is  given. 

While  this  is  being  accomplished,  a  cereal  from  the  cup 
and  spoon  may  be  introduced  into  the  diet  and  the  infant 
encouraged  to  acquire  a  taste  for  it.  At  first  enough  will 
not  be  taken  to  make  an  entire  feeding,  so  that  it  is  neces- 
sary to  finish  this  feeding  with  the  bottle.  The  infant  should 
be  allowed  to  take  all  the-  cereal  it  will  from  the  spoon  and, 
after  six  or  eight  ounces  are  taken  at  one  time,  the  bottle  is 
omitted  at  this  feeding.  At  nine  or  ten  months  of  age  still 
another  cereal  meal  may  be  given  and  the  bottle  omitted 
at  that  time.  In  the  meantime,  a  stale  piece  of  bread,  zwie- 
back or  plain,  unsweetened  cracker  may  be  given  in  the  hand 
after  any  or  all  of  the  bottle  feedings. 

The  cereal  should  be  made  as  thick  as  an  ordinary  gruel, 
and,  after  it  is  cooked  thoroughly,  thinned  down  with  milk. 
It  should  be  salted  to  taste,  but  not  sweetened.  Infants  often 
dislike  the  gritty  taste  of  farina  or  cream  of  wheat,  so  it  is 


BOTTLE  WEANING  319 

best  to  begin  with  barley,  rice  flour,  arrowroot  or  strained 
oatmeal  grueL  Later  on,  farina,  cream  of  wheat,  wheatena 
or  oatmeal  unstrained  may  be  given  and  are  valuable  in 
helping  the  child  to  acquire  a  taste  for  different  kinds  of 
foods. 

CASE  LXXV 

(Illustrating  the  weaning  of  a  bottle-fed  infant  at  8  months  of  age) 
May  24:     Age,  8  months  2  weeks.    Birth  weight,  9  Ib. 

Present  weight,  19  Ib.  15  oz. 

General  Condition. — Fat,  normal  infant.     Needs  from  40  to  45  calories  per 

pound  per  day. 

Stools. — One  or  two  normal  a  day. 
Vomiting. — None. 
Appetite. — Excellent. 
Temperature,  98.6°  F. 

Previous  Food: 

Milk 32       oz.  640  cal.      Fed  8  ounces  every  3  hours  at  6, 

Barley  gruel  . .  10       oz.  100  cal.          9,  12  A.M.,  3,  6,  9  P.M. 

Dextri-maltose .  1%  oz.  180  cal. 

920  cal.,  or  45  cal.  per  Ib. 

For  the  last  two  weeks  has  been  getting  thick  barley  gruel,  fed  from  the 
spoon  just  before  the  12  M.  bottle,  and  is  now  having  4  or  5  ounces  of  this  gruel. 

Treatment. — Food  prescribed: 

Milk  32  oz.      Divide  into   5  bottles  of   8  oz.  each 

Water    10  oz.          and  feed  at  6,  10  A.M.,  2,  6,  10  P.M. 

Dextri-maltose 1  oz. 

At  10  A.M.  and  2  P.M.  barley  gruel  with  milk  upon  it  should  be  given  in 
addition  to  the  bottle. 

June  7    (two  weeks  later)  :     Weight,  20  Ib.  6  oz. 

Gain,  7  oz. 

General  Condition. — As  at  last  visit. 
Stools. — Two  normal. 
Vomiting. — None. 

Appetite. — Takes  bottle  and  gruel  well. 
Sleep. — Excellent. 

Treatment. — Food  prescribed : 

Bottle  Feedings. — Each  day  decrease  the  water  one  ounce,  using  the  same 
amount  of  milk    (one  quart).     Gradually  decrease  the  dextrose  maltose  by 


320 

putting  in  one  tablespoonful  less  every  other  day,  until  the  baby  is  getting 
undiluted,  unsweetened  milk  from  cup  or  bottle. 

Cereal. — Give  a  cereal  feeding  at  first  once  a  day,  in  one  week  twice  a  day, 
and  ( if  the  baby  takes  it  well )  the  following  week  three  times  a  day.  A  cereal 
should  be  cooked  at  least  three  hours,  salted  to  taste  and  made  as  thick  as 
you  would  eat  it  yourself,  or  thinner  if  the  baby  likes  it  that  way.  It  should 
be  eaten  with  full  milk  but  no  sugar  upon  it.  Cereals  should  be  varied  from 
day  to  day  with  barley  jelly,  oatmeal,  farina,  cream  of  wheat,  rice,  wheatina 
and  Ralston's  food.  At  first  barley  jelly  (made  with  either  Robinson's  or 
Brook's  barley  flour  or  pearl  barley)  is  the  best  to  give  until  the  baby  has 
become  accustomed  to  taking  a  cereal,  and  later  the  cereals  should  be  varied 
from  day  to  day.  One  kind  of  cereal  a  day  is  sufficient  and  may  be  prepared 
in  the  morning  for  the  whole  day.  If  the  bowels  are  constipated,  wheatina, 
oatmeal  and  Ralston's  food  should  be  given  more  often  than  cream  of  wheat 
or  farina.  Baby  may  have  all  the  cereal  desired. 

When  a  double  boiler  is  used  the  cereal  should  be  brought  to  a  boil  over 
the  direct  heat  and  then  cooked  in  the  double  boiler  for  three  hours.  A  fireless 
cooker  is  a  most  excellent  means  of  cooking  cereals  for  children,  cooking  the 
cereal  in  the  cooker  all  night. 

Breadstuffs. — Zwieback  (either  that  which  is  bought  or  made  at  home 
by  browning  slices  of  bread  hard  and  dry  in  the  oven).  Give  dry  in  the  hand, 
never  between  feedings,  but  immediately  before  or  after  a  feeding,  or  it  may 
be  taken  in  the  hand  while  baby  is  eating  the  cereal.  Occasionally  it  may  be 
given  soaked  in  milk  instead  of  cereal  (if  the  baby  likes  it  that  way),  but 
not  customarily,  because  at  this  age  baby  needs  to  have  some  dry  food.  A 
graham  cracker  may  be  given  immediately  before  or  after  a  feeding  if  the 
bowels  are  constipated.  If  the  bowels  become  too  loose,  stop  the  graham 
crackers.  Three  or  four  graham  crackers  should  be  enough  in  twenty-four 
hours,  but  no  limit  need  be  put  on  the  quantity  of  zwieback  or  dry  bread. 
No  butter  should  be  given. 

Fruit. — Apple  sauce  (with  very  little  if  any  sweetening)  may  be  given 
ence,  twice  or  three  times  a  day  if  the  bowels  remain  constipated.  Prunes 
should  be  cooked  soft  in  very  little  water  and  no  sugar.  Before  they  are  done 
allow  the  water  to  boil  down  so  that  there  is  a  small  amount  of  juice.  Take 
out  the  seeds  and  press  the  prunes,  skin  and  juice  through  a  fine  wire  colander. 
Give  only  a  few  teaspoonfuls  at  first  and  gradually  increase  the  amount. 
It  is  not  harmful  to  give  cooked  fruit  at  the  same  meal  with  milk.  Orange 
juice  may  be  given  one  hour  before  one  of  the  feedings  once  a  day,  using  the 
juice  of  a  whole  orange. 

Milk. — Encourage  baby  to  drink  milk  from  a  cup,  by  pouring  part  of  the 
bottle  feeding  into  a  cup,  taking  as  much  in  this  way  as  possible  without  making 
it  extremely  disagreeable.  It  is  important  that  baby  should  learn  to  drink  milk 
from  a  cup  at  this  age,  since1  babies  who  take  milk  well  throughout  childhood 
are  usually  strong  and  robust,  provided  they  get  the  proper  amount  of  other 
food.  The  bottle  feedings  may  always  be  used  to  finish  a  meal  if  all  the  milk  is 
not  taken  from  the  cup.  One  quart  of  milk  should  be  taken  each  day  throughout 
childhood,  although  the  other  food  is  equally  important. 


BOTTLE  WEANING  321 

If  any  of  the  food  suggested  on  this  diet  list  is  refused,  a  little  should  be 
given  each  day  and  the  baby  made  to  swallow  at  least  a  mouthful  of  it  until  the 
taste  for  it  is  acquired,  provided  it  doee  not  actually  disagree  or  cause  digest- 
ive disturbances. 

DAY'S  SCHEDULE  (eventually) 
6  A.M.: 

8-10  ounces  of  milk  from  bottle. 
Zwieback,  toast  or  graham  cracker. 

8  A.M.: 

The  juice  of  a  whole  orange. 

10  A.M.: 

Cereal. 

Milk  from  cup. 

Breadstuffs. 

Prunes. 

Follow  with  bottle  if  sufficient  food  is  not  taken  from  cup  and  spoon. 

2  P.M. : 

Cereal. 

Milk  from  cup. 

Breadstuffs. 

Apple  sauce  if  constipated. 

Bottle  if  necessary. 

$  P.M. : 

Cereal. 

Milk  from  cup. 

Breadstuffs. 

Apple  sauce  if  constipated. 

Bottle  if  necessary. 

10  P.M.: 

8-10  ounces  of  milk  in  bottle. 

Diet  at  Twelve  to  Fourteen  Months  of  Age. — At  twelve 
months  of  age  the  child  should  be  having  three  meals  a  day  in 
addition  to  its  two  bottles.  These  meals  should  be  as  follows : 

6  A.M.: 

8  ounces  of  milk  from  bottle. 
Breadstuffs. 

9  A.M.: 

Juice  of  a  whole  orange. 

10  A.M.: 

Cereal. 

Milk  from  cup  (8  ounces). 

21 


322  SIMPLIFIED  INFANT  FEEDING 

Breadstuff's. 

Apple  sauce  or  prunes. 

Finish  with  bottle  if  sufficient  food  is  not  taken. 

2  P.M. : 

Give  at  first  small  baked  potato  with  salt  and  a  little  milk  if  the  baby  likes 
it  moistened.     In  a  few  days  if  it  agrees  with  the  baby  a  large  baked 
potato  may  be  given  at  this  meal  (and  at  the  end  of  two  weeks  butter  may 
be  put  on  it  instead  of  milk).     In  a  few  days  begin  a  vegetable  besides 
the  potato,  either  carrots,  spinach,  green  peas,  string  beans  or  asparagus 
tips.    It  is  best  to  start  with  the  spinach.     A  teaspoonful  or  two  only  is 
given  at  first  and  the  amount  gradually  increased  up  to  one  or  two  table- 
spoonfuls.     Vary  vegetables  from  day  to  day. 
Breadstuff  s. 
Milk  from  cup. 
Apple  sauce  or  prunes  if  constipated. 

6  P.M.: 
Cereal. 

Milk  from  cup. 
Breadstuff's. 

Apple  sauce,  baked  apple  or  prunes. 
Follow  by  bottle  if  necessary. 

10  P.M.: 

8-10  ounces  of  milk  in  bottle. 

One  quart  of  milk  a  day  should  be  taken. 

Diet  at  Fourteen  or  Fifteen  Months  of  Age. — At  fifteen 
months  of  age  an  egg  may  be  added  to  the  diet.  Before  this 
time  the  child  has  become  accustomed  to  the  vegetables  so 
that  a  fairly  large  quantity  can  now  be  taken.  Vegetables 
contain  iron  which  is  much  needed  at  this  period. 

Eaw  fruits  such  as  scraped  apple,  pear,  peach  or  an 
orange  may  be  given  between  meals,  particularly  if  there  is 
a  tendency  toward  constipation. 

By  fourteen  or  fifteen  months  of  age,  at  most,  the  child's 
bottle  feedings  should  be  cut  down  to  one,  and  three  meals  a 
day  should  be  given.  The  feedings  may  be  given  in  the  fol- 
lowing order: 

6-7  A.M.: 

Orange  juice. 
7-8  A.M.     Breakfast: 

Cereal  (with  milk  but  no  sugar  on  it,  cooked  at  least  three  hours) :  Vary 


BOTTLE  WEANING  323 

cereals  each  day  with  oatmeal,  Quaker  Oats,  rice,  cream  of  wheat,  wheat- 

ina,  farina,  pettijohn,  hominy,  cornmeal  mush  and  Ralston's  food.    No 

ready  cooked  cereals. 

Milk  from  the  cup  (all  baby  will  take). 

Breadstuffs. 

12-12.30  P.M.     Dinner: 

Vegetables :  Baked  potato  with  butter  on  it  and  one  other  vegetable  each 

day,  carrots,  spinach,  string  beans,  green  peas  or  asparagus  tips. 

Egg:  Coddled  (to  coddle  an  egg  place  it  in  cold  water  on  the  stove  and 

allow  the  water  to  come  to  a  boil  rather  slowly.     When  the  water  boils 

the  egg  is  cooked.     Cooked  in  this  way  the  white  is  soft  and  jelly-like 

and  the  yolk  somewhat  set).     Give  only  a  few  tablespoonfuls  at  first  and 

gradually  increase  the  quantity  until  at  the  end  of  a  week  or  so  one  egg 

is  taken  every  other  day.     The  following  week  give  one  egg  each  day 

at  this  meal. 

Milk  from  cup. 

Breadstuffs. 

5  P.M.     Supper: 
Milk  from  cup. 
Breadstuffs. 
Cooked  fruit:  Apple  sauce,  baked  apple  or  prunes. 

10  P.M.: 

Milk :  8  ounces  of  milk  in  a  bottle. 

At  least  one  quart  of  milk  should  be  taken  in  twenty-four  hours,  but  none 
between  meals. 

Diet  at  Two  Years  of  Age. — At  two  years  the  child  may 
have  meat  added  to  its  diet,  provided  the  teeth  have  properly 
erupted.  The  meals  are  now  cut  down  to  three  a  day  and 
should  be  given  as  follows : 

7-8  A.M.     Breakfast: 

Cereal  (cooked  at  least  two  hours,  with  milk  but  no  sugar  on  it)  :  Vary 

cereals  each  day  with  oatmeal,  Quaker  Oats,  Scotch  oatmeal,  cream  of 

wheat,   farina,   wheatina,    pettijohn,   hominy,    rice,   cornmeal   mush   and 

Ealston's  food.     No  ready-cooked  cereals. 

Milk. 

Breadstuffs. 

Egg:   Coddled,  should  be  given  at  breakfast  only  two  or  three  times  in 

a  week. 

12-12.30  P.M.     Dinner: 

Meat:  A  small  piece  of  meat  cut  very  fine.  At  first  mash  the  meat  in 
with  the  potato  and  give  three  or  four  times  a  week.  A  coddled  egg  should 
be  substituted  for  the  meat  on  the  days  when  no  egg  has  been  given  in  the 
morning.  The  white  meat  of  chicken,  roast,  boiled  or  broiled;  lamb  chop, 


324  SIMPLIFIED  INFANT  FEEDING 

tenderloin  steak,  round  steak  shredded  with  a  fork  (all  cooked  rare). 
In  a  month  or  two  when  baby  has  become  accustomed  to  these  meats, 
roast  beef,  roast  lamb  and  Hamburger  steak  may  be  given  occasionally 
(all  cooked  rare,  except  chicken). 

Vegetables:  Baked  potato  and  one  other  vegetable  every  day;  vary  with 
green  peas,  string  beans,  asparagus  tips  (all  canned  when  out  of  season), 
carrots,  spinach  and  tender  young  beets  thoroughly  mashed. 
Breadstuff s. 

Dessert:  Apple  sauce,  baked  apple,  prunes  (all  cooked  with  the  minimum 
amount  of  sugar),  cut  oranges  and  grape  fruits. 
5-5.30  P.M.     Supper: 

Milk:    All  the  baby  will  take. 
Breadstuffs. 

Fruit:  Apple  sauce,  baked  apple,  prunes,  cut  fruit  such  as  oranges,  grape- 
fruit, scraped  apple,  pears,  peaches,  plums,  apricots  when  in  season.  (It 
is  not  harmful  to  give  fruit  at  the  same  meal  with  milk. ) 

Diet  at  Two  and  One-half  to  Three  Years. — 

Breakfast : 

Cereal  (with  milk  but  no  sugar,  cooked  at  least  two  hours) :  Vary  cereal 

each  day.     No  ready-cooked  cereals. 

Milk. 

Breadstuff  s. 

Egg:   Soft  boiled,  coddled,  poached,  scrambled   (scrambled  in  a  saucepan 

over  a  low  fire,  with  milk  but  no  butter ) . 

Bacon:  Cut  very  thin  like  Beachnut  bacon  and  cooked  dry  enough  to  eat 

with  the  fingers.     Occasionally  crumbled  in  the  egg  for  variety's  sake. 

Dinner : 

Meat:  Vary  meat  each  day,  giving  lamb  chop,  steak,  Hamburger  steak, 
roast  beef,  lamb   or  veal    (roasts  either   cold  or  hot),  all  cooked  rare. 
Chicken  boiled,  roast  or  broiled.     No  thickened  gravies. 
Fish  (once  a  week)  :  Baked  or  boiled. 

Vegetables:  Potatoes  baked,  boiled  or  mashed.     At  least  one  other  vege- 
table each  day,  green  peas,  string  beans,  asparagus  tips,  small  lima  beans 
(all  canned  when  out  of  season),  beets,  carrots,  spinach,  cooked  celery, 
lettuce  and  raw  celery  but  no  other  uncooked  vegetables. 
Breadstuffs. 

(Dessert:  Apple  sauce,  baked  apple,  stewed  rhubarb,  prunes,  cut  oranges 
and  grapefruit.  Occasionally  custard,  junket,  rice  pudding,  bread  pud- 
ding and  tapioca  pudding  or  ice  cream,  all  made  without  too  much 
sweetening. 

Supper : 

Milk  or  cocoa  (made  with  milk  and  very  little  sweetening). 

Breadstuffs. 

Creamed  soups  (made  with  milk  but  not  much  butter)  :  Potato,  dry  pea  or 


BOTTLE  WEANING  325 

bean,  green  pea  or  lima  bean,  asparagus,  celery,  corn  (strained),  tomato 
(very  little  tomato  in  it).  Clear  meat  broths  only  occasionally,  as  they 
do  not  contain  much  nourishment. 

Fruit:  Apple  sauce,  baked  apple  or  prunes.  Raw  fruit  such  as  grapefruit, 
apples,  pears,  peaches,  plums,  apricots  and  berries  in  season  when  very 
ripe  and  sweet.  If  fruits  are  cooked  very  little  sugar  should  be  used. 

This  diet  should  not  be  altered  materially  until  the  school 
age  is  reached,  when  it  may  become  necessary  to  change  it 
somewhat  to  meet  existing  conditions.  All  really  necessary 
foods  are  contained  in  this  diet,  and  enough  variety  in  the 
kinds  of  foods  should  be  permitted  so  that  it  may  not  become 
distasteful  through  monotony.  Meat  should  not  be  given 
more  than  once  a  day  until  the  tenth  or  twelfth  year.  If  it  is 
at  all  possible,  the  hearty  meal  should  be  eaten  in  the  middle 
of  the  day  throughout  childhood.  If,  after  the  beginning 
of  the  school  age,  this  is  not  possible,  the  noon  meal  should 
be  supplemented  by  a  nourishing  dessert,  such  as  a  custard 
or  milk  pudding.  A  child  should  never  be  put  to  bed  in 
less  than  two  hours  after  a  hearty  meal. 

FOODS 

Bread  should  always  be  given  stale.  White  bread,  whole 
wheat  bread,  graham  bread,  rye  bread  and  bran  biscuits 
may  be  given  for  the  sake  of  variety.  It  is  best  put  into  the 
oven  until  it  is  brown  and  hard  all  the  way  through. 

The  more  nourishing  of  the  crackers  may  occasionally 
be  given  with  the  evening  meal.  Hard-tack,  soda  crackers, 
oatmeal  crackers,  graham  crackers,  egg  biscuit,  rice  and 
arrowroot  wafers,  with  an  occasional  sweetened  cracker  for 
dessert  at  supper,  are  allowable.  Griddle  cakes  and  hot 
breads  are  prohibited. 

Cereals  should  be  given  but  once  a  day  after  fifteen  months 
of  age.  They  should  be  well  cooked,  in  milk  or  water,  and 
should  always  be  cooked  one  to  three  hours,  according  to 
the  coarseness  of  the  grain.  Undercooked  cereals  are  the 
source  of  much  stomach  disturbance.  It  is  therefore  well 


326  SIMPLIFIED  INFANT  FEEDING 

to  cook  them  the  night  before,  as  they  are  apt  to  be  under- 
done when  hastily  cooked  for  breakfast.  Wheatina,  farina, 
rice,  cream  of  wheat,  Scotch  and  Irish  oatmeal,  rolled  oats, 
cornmeal  mush,  hominy,  samp,  Ralston 's  food,  pettijohn, 
are  all  excellent  cereals.  They  should  be  eaten  with  milk 
but  without  sugar,  for  sugar  at  the  morning  meal  usually 
destroys  the  appetite  for  the  balance  of  the  meal,  which  the 
child  needs  for  its  different  food  elements.  The  ready- 
cooked  cereals  may  sometimes  be  given  to  older  children, 
but  their  extensive  use  is  not  recommended. 

Vegetables. — A  frequent  mistake  is  the  omission  of  vege- 
tables during  the  first  half  of  the  second  year.  From  the 
theoretical  standpoint  this  would  seem  to  be  wrong,  since 
it  is  just  at  this  age  that  the  child  needs  iron  and  other  salts 
which  the  vegetables  contain.  The  child  has  been  fed  upon  a 
milk  diet  throughout  the  first  year,  and  milk  is  deficient 
in  iron  and  other  necessary  mineral  constituents.  Theo- 
retically, also,  the  infant  is  born  with  enough  iron  stored  up, 
principally  in  the  liver,  to  last  him  throughout  the  first  year. 
From  a  practical  standpoint,  many  children  who  are  not 
given  vegetables  are  anaemic,  even  though  the  diet  has 
been  most  carefully  regulated  according  to  our  Ameri- 
can standards. 

It  has  been  the  author's  custom,  therefore,  to  give  potato 
once  a  day,  and  one  other  vegetable  along  with  it,  at  the 
latest,  by  the  beginning  of  fhe  second  year.  It  is  necessary 
to  cook  these  vegetables  thoroughly  so  that  they  are  soft,  but 
vegetables  must  not  be  overcooked,  as  too  much  cooking 
destroys  the  vitamines.  The  water  should  never  be  thrown 
away  since  it  contains  iron  and  other  desirable  minerals. 
When  boiling  use  a  minimum  amount  of  water  at  first,  and 
when  the  vegetable  is  nearly  done,  take  off  the  cover  and 
allow  the  water  to  evaporate  in  the  form  of  steam,  leaving 
the  minerals  in  the  vegetable.  At  first  mash  them  so  that 
they  contain  no  hard  particles,  as  a  child  at  this  age  is  unable 


BOTTLE  WEANING  327 

to  masticate  well  because  of  lack  of  teeth.  Beginning  with 
potatoes,  which  should  be  boiled,  baked  or  mashed,  other 
vegetables  are  gradually  added.  Peas,  string  beans,  car- 
rots, spinach,  asparagus  tips,  beets,  are  all  suitable  vege- 
tables for  the  child.  Vegetables  such  as  cabbage,  cauli- 
flower, onions,  shelled  beans,  tomatoes,  lettuce,  celery,  tur- 
nips or  sweet  potatoes  should  not  be  added  to  the  diet  until 
the  third  year. 

Meat. — The  first  meat  given  should  be  rare  beef  scraped 
and  mixed  with  the  potato.  The  quantity  may  be  gradually 
increased  and,  after  a  few  weeks,  other  meats  are  added. 
Beef,  roasted  or  broiled  or  chopped;  lamb,  roasted  or 
broiled;  veal,  roasted  or  broiled;  fish,  boiled;  and  chicken, 
roasted,  broiled  or  boiled,  may  be  added  to  the  diet.  Pork, 
ham,  sausage,  liver,  tripe,  or  thickened  gravies  should  never 
be  given  to  young  children.  Bacon  cooked  dry  enough  to 
eat  with  the  fingers  may  be  allowed  after  the  middle  of  the 
second  year.  Boiled  meats,  with  the  exception  of  chicken, 
are  not  permitted  at  first. 

Children  who  do  not  get  the  proper  amount  of  proteid  in 
the  diet  are  very  apt  to  be  large  eaters,  and,  consequently,  to 
overeat.  Sometimes  this  overeating  is  of  foods  which  are 
more  difficult  to  digest  than  the  meats.  There  seems  to  be  a 
widespread  tendency  among  the  laity  not  to  give  meat  dur- 
ing the  second  and,  often,  during  the  third  years.  There  is 
also  a  tendency,  after  five  years  of  age,  to  give  meat  more 
than  once  a  day,  which  is  almost  as  bad  as  the  absence  of  it. 

Eggs  should  be  boiled  or  coddled.  They  are  coddled  by 
putting  them  into  cold  water  and  placing  them  on  the  stove 
until  the  water  comes  to  a  boil.  After  taking  them  off  the 
stove,  they  are  allowed  to  remain  in  the  water  for  a  minute 
or  two.  Cooked  in  this  way  the  whites  are  soft  and  jelly-like 
instead  of  being  hard  and  leathery ;  the  yolks  are  slightly 
cooked,  thus  making  them  far  more  easily  digested.  Eggs 
are  an  essential  item  of  the  diet  and  if,  at  first,  they  are  not 


328  SIMPLIFIED  INFANT  FEEDING 

well  taken  each  day,  only  a  spoonful  is  given,  increasing  the 
amount  as  it  becomes  possible  to  do  so.  Fried  eggs  have  no 
place  in  a  child's  dietary. 

Clear  Meat  Soups  are  of  little  value.  Thickened,  they  are 
often  indigestible  and  the  clear  meat  broths  have  very  little 
nutrient  value.  The  author  omits  broths  from  his  diet  lists 
for  well  children,  except  where  a  clear  broth  is  given  as  a 
vehicle  for  the  bread,  vegetables  and  other  foods.  They  are 
sometimes  useful  in  stimulating  the  appetite. 

It  has  long  been  understood  that  soups  and  broths  have 
little  nutrient  value  and  contain  only  the  extractives  of  meat. 
The  child  who  takes  a  meal  of  soup  gets  very  little  nourish- 
ment except  for  the  bread  or  whatever  else  is  eaten  with  it. 
It  is  difficult  to  see,  therefore,  why  a  soup  should  be  advised 
in  every  dietary  for  children.  Usually  they  do  not  need  a 
vehicle  in  which  to  take  the  bread  or  other  carbohydrates, 
because  most  children  eat  these  without  urging. 

Desserts  may  be  given  after  the  second  year.  Children 
whose  appetites  are  poor  should  be  allowed  no  desserts  or 
sweets  of  any  kind. 

Sugar  is  an  article  of  food  which  probably  causes  more 
digestive  disturbances  than  any  other  one  thing.  We  some- 
times hear  it  argued  that  children  have  a  craving  for  sweets 
and  that  this  craving  should  be  satisfied.  Those  who  come  in 
intimate  contact  with  children  soon  learn  that  their  cravings 
are  not  guides  to  their  requirements.  Sugar  is  a  very  con- 
centrated form  of  nourishment,  and  its  high  caloric  value 
takes  away  the  appetite  from  other  foods  which  are  neces- 
sary. Often  children  who  have  their  diet  carefully  regu- 
lated, particularly  as  they  get  older,  get  a  certain  amount 
of  sweets  in  spite  of  any  restriction  that  is  put  upon  them. 
No  matter  how  much  we  may  say  to  the  parents  upon  this 
subject,  the  sweets  are  always  forthcoming.  It  is  therefore 
best  to  limit  sweet  desserts  to  the  noon  meal,  and,  if  possible, 
to  prohibit  them  at  all  other  times.  The  desserts  may  be 
given  at  the  end  of  the  second  year  and  may  consist  of  rice- 


BOTTLE  WEANING  329 

pudding,  blanc-mange,  gelatin  puddings,  farina,  soft  and 
hard  custards,  ice  cream,  sponge  cake  or  lady  fingers,  dry  or 
with  whipped  cream,  angel  cake  or  sweetened  crackers.  No 
other  cakes  or  pastries  are  allowed  until  after  the  twelfth 
year.  Special  care  should  be  given  to  prevent  the  use  of 
sugar  upon  the  cereals  or  fruits,  and  of  candy  between  meals 
or  at  any  other  time. 

Fruits. — The  place  of  fruits  in  the  child's  diet  is  a  very 
important  one.  They  help  to  regulate  the  bowels,  and  offer 
the  other  elements  of  the  food  which  are  very  necessary. 
Why  it  is  that  uncooked  fruits  are  not  allowed  is  difficult  to 
understand,  but  such  is  the  dictum  of  many  pediatrists. 
Fruits  are  no  more  easily  digested  when  cooked  than  when 
raw,  especially  since  the  custom  of  cooking  them  with  sugar 
is  a  general  one.  From  a  practical  standpoint,  the  author 
has  long  given  uncooked  fruits,  even  during  the  latter  part 
of  the  first  year,  and  has  never  found  that  the  well  child  had 
any  difficulty  in  digesting  them,  if  they  were  given  properly. 
They  are  indigestible  if  swallowed  in  hard  pieces ;  therefore, 
until  the  end  of  the  second  year,  before  the  teeth  have  all 
come  and  before  the  child  has  learned  to  masticate  thor- 
oughly, it  is  best  to  give  them  scraped  or  mashed.  A  ripe 
apple  or  pear  when  scraped  with  a  spoon  is  allowed  once 
or  twice  a  day,  or  even  more  if  the  bowels  require  it.  Chil- 
dren are  usually  fond  of  fruits  served  in  this  way,  and  they 
are  more  easily  digested  than  prunes  and  other  dried  fruits 
which  are  often  exclusively  advised  for  constipation. 

For  variety's  sake,  however,  fruits  may  be  given  either 
raw  or  cooked.  Berries  may  be  given  after  the  third  year. 

Special  Food  for  Sick  Children.— Children  when  they  are 
ill  should  not  as  a  rule  be  forced  to  eat  or  made  to  eat  things 
which  they  dislike.  Neither  should  they  be  encouraged  nor 
allowed  to  drink  large  quantities  of  milk  at  irregular  in- 
tervals to  quench  the  thirst  during  a  fever,  which  is  a 
oommon  practice. 

All  food  ought  to  be  temporarily  discontinued  at  the 


330  SIMPLIFIED  INFANT  FEEDING 

beginning  of  any  illness,  and  particularly  so  where  there  is 
fever.  At  this  time  clear  broths  and  soups  are  an  advantage, 
containing  as  they  do  only  a  minimum  amount  of  nutriment 
which  is  not  apt  to  overtax  the  digestion. 

Beef,  lamb  and  chicken  broths  are  allowable  and  should 
be  made  in  the  following  manner :  Allow  the  meat,  after  it 
has  been  chopped,  to  stand  in  cold  water  for  an  hour  or  two, 
when  it  may  be  placed  upon  the  stove  and  brought  to  a  tem- 
perature of  160°  F.,  but  never  to  the  boiling  point.  After 
simmering  for  two  hours,  it  should  be  set  away  to  cool  so 
that  the  fat,  which  will  then  rise  to  the  top  and  harden, 
can  be  removed. 

When  gruels,  which  are  sometimes  more  easily  digested 
than  milk,  are  given,  they  should  be  made  with  water,  a  little 
salt  being  added,  and  they  must  be  well  cooked.  They  are 
best  made  in  the  f ollowing  manner :  Two  or  four  tablespoon- 
fuls  of  the  flour  (the  amount  varying  with  the  age  of  the 
child)  to  one  quart  of  water  are  used.  First  a  thin  paste 
should  be  made  of  the  flour  with  a  little  cold  water  and,  when 
this  is  free  from  lumps,  it  may  be*1  stirred  into  the  proper 
amount  of  boiling,  salted  water.  It  may  then  be  placed  on 
the  back  of  the  stove  and  left  to  boil  gently  for  a  half  hour, 
unless  it  is  cooked  in  a  double  boiler,  in  which  case  it  should 
boil  at  least  one  hour. 

Barley,  arrowroot,  farina,  cornstarch,  wheat  flour, 
cracker  flour,  rice  flour,  oatmeal,  cornmeal,  and  browned 
flour  gruels  are  all  admirable  for  the  sick  child.  Browned 
flour  gruel  is  made  by  putting  the  flour  into  an  oven  and 
browning  it  all  the  way  through,  stirring  it  from  time  to  time 
to  prevent  burning.  An  oatmeal  or  other  coarse  gruels 
should  not  be  used  in  diarrhea.  Gruels  may  be  dextrinized 
by  adding  a  teaspoonful  of  Cereo  l  to  them,  after  they  are 
cooked  and  have  cooled  to  a  temperature  a  little  above  blood 
heat.  This  dextrinization  changes  the  starch  to  dextrin 

1  Made  by  The  Cereo  Company,  Tappan,  N.  Y. 


BOTTLE  WEANING  331 

and  maltose  and,  during  the  process,  thins  even  a  thick 
gruel  to  a  watery  consistency. 

For  the  sake  of  variety  breaded  pap  and  junket  may  be 
given  to  the  sick  child.  The  former  consists  of  thin  slices  of 
white  bread  thoroughly  browned  in  an  oven,  after  which  they 
are  put  into  a  saucepan  with  sufficient  water  to  moisten  them 
and  brought  to  a  boil.  If  there  are  no  contra-indications 
this  may  be  made  with  milk  instead  of  water  and  slightly 
sweetened  with  cane  sugar.  Junket  is  made  by  adding  a 
teaspoonful  of  essence  of  pepsin  to  one-half  pint  of  fresh 
milk  heated  to  blood  temperature.  After  the  flavoring  and 
a  little  sugar  (provided  this  is  not  prohibited  in  the  diet) 
have  been  added,  it  should  be  poured  into  cups  and  allowed 
to  remain  undisturbed  until  it  jellies.  The  nutritive  value  of 
the  junket  may  be  increased  by  adding  a  thoroughly  beaten 
raw  egg  to  the  milk  before  it  is  heated.  Junket  tablets,  which 
can  be  obtained  from  any  druggist  or  grocer,  may  be  used 
instead  of  the  pepsin  if  so  desired. 


CHAPTER  XXVII 

THE  PREMATURE  INFANT— FOOD  FOR  TRAVEL- 
LIN  G— WATER— LAVAGE— GAVAGE— IRRI- 
GATING THE  BOWELS 

THE  PREMATURE  INFANT 

THE  premature  infant  rarely  lives  when  born  before  the 
twenty-eighth  week  of  intra-uterine  life,  but  from  then  on 
each  week  added  to  its  intra-uterine  life  will  add  to  its 
chances  of  living.  While  it  is  not  invariably  the  case,  yet 
in  most  instances  the  larger  and  heavier  the  infant  at  birth, 
the  greater  will  be  its  chances  for  life.  Any  infant  weighing 
less  than  four  pounds  should  be  treated  as  though  it  were 
premature,  since  many  of  the  organs  are  likely  to  be  imper- 
fectly developed,  especially  the  lungs  and  the  organs  of 
digestion,  and  lack  of  strength  in  the  muscles  of  deglutition 
makes  it  impossible  for  the  infant  to  suckle  properly. 

Four  factors  determine  success  in  keeping  a  premature 
infant  alive  and  making  it  thrive :  First,  equitable  tempera- 
ture; second,  little  handling;  third,  proper  nursing;  and, 
fourth,  the  food. 

Equitable  Temperature. — There  has  been  a  great  deal  said 
both  for  and  against  incubators,  some  authorities  believing 
that  the  incubator  is  a  great  source  of  danger  and  recom- 
mending the  universal  use  of  a  basket,  properly  protected 
and  with  some  suitable  means  of  supplying  artificial  heat, 
such  as  an  electric-  warming  pad,  or  so  arranged  that  the 
infant  may  be  surrounded  by  hot-water  bottles  covered  with 
a  soft  pad.  Undoubtedly  the  incubator  is  the  ideal  method 
of  maintaining  even  temperature,  provided  that  there  is  a 
constant  supply  of  fresh  air  which  cannot  possibly  fail ;  that 
the  air  is  not  burned  up  by  the  heating  process,  and  that  it  is 
832 


THE  PREMATURE  INFANT  333 

under  the  constant  care  of  a  nurse  who  is  familiar  with 
incubators  and,  therefore,  knows  how  to  run  them. 

I  have  never  seen  an  incubator  that  will  run  itself  with- 
out supervision.  Many  of  the  so-called  automatic  incubators 
are  supposed  to  do  so,  especially  those  that  are  heated  with 
incandescent  lights  which  go  out  when  the  temperature  gets 
above  a  certain  point  and  are  flashed  on  again  when  the 
temperature  goes  below  a  certain  point.  However,  in  spite 
of  this  ingenious  contrivance,  accidents  occasionally  happen, 
so,  to  insure  safety,  a  nurse  must  watch  every  moment,  both 
night  and  day. 

A  very  excellent  substitute  for  the  incubator,  and  one 
which  is  far  safer  for  the  novice,  or  even  the  trained  nurse 
who  has  not  had  experience  with  the  more  complicated  incu- 
bators, is  made  in  the  following  manner :  the  framework  is 
made  of  two  barrel  hoops  cut  in  halves.  These  are  nailed 
together  with  longitudinal  strips  of  wood  to  form  a  tent 
the  size  of  a  basinette  or  basket.  It  is  then  covered  with 
heavy  cotton  cloth  or  a  blanket  to  make  the  tent.  Sus- 
pended from  the  top  of  the  tent  on  the  inside  are  electric 
light  bulbs  attached  to  a  cord,  which  is  of  course  connected 
to  the  current.  Two  to  four  bulbs  may  be  used  according 
to  the  temperature  desired  and  also  the  season  of  the  year. 
The  tent  may  be  left  open  at  the  head  for  ventilation  or  it 
may  be  so  placed  upon  the  baby  that  the  head  is  outside  of  the 
tent,  thus  insuring  plenty  of  fresh  air. 

The  infant's  temperature  varies  greatly  with  the  changes 
in  temperature  of  the  air  and  also  with  the  amount  of  food  it 
receives  and  digests.  A  rise  in  body  temperature  to  101°, 
102°  F.  or  more  may  be  due  either  to  a  too  high  temperature 
in  the  incubator,  or  to  starvation  or  underfeeding  of  the 
infant,  or  imperfect  development  of  the  infant's  heat  centre, 
or  to  some  intercurrent  affection.  The  premature  infant 
that  runs  a  continuous  subnormal  temperature  is  doing  no 
better  than  the  one  who  has  a  temperature  above  normal.  If 


334  SIMPLIFIED  INFANT  FEEDING 

the  temperature  goes  down  to  96°  F.  or  even  95°  F.  and  does 
not  rise  above  97°  F.,  life  is  at  low  ebb  and  the  prognosis 
is  not  good.  A  temperature  that  has  great  variations,  per- 
haps running  from  subnormal  temperature  to  two  or  three 
degrees  above  the  normal  point,  is  also  of  bad  import.  This 
may  mean  that  something  is  wrong  with  the  external  heating 
apparatus  so  that  the  temperature  is  not  being  kept  even, 
or  that  the  infant  is  not  doing  well  from  some  other  cause. 

When  the  premature  infant  runs  an  even,  normal  tem- 
perature, a  very  much  better  prognosis  can,  of  course,  be 
made  than  is  possible  under  the  above-mentioned  conditions. 
It  is  usually  evident  from  a  normal  temperature  of  this  sort 
that  the  feeding  is  well  borne  and  that  the  external  heat  is 
properly  managed. 

Little  Handling. — The  premature  infant  should  get  a  mini- 
mum amount  of  handling.  Not  only  is  handling  hurtful  in 
itself,  but  the  less  an  infant  is  taken  out  of  the  warm  sur- 
roundings, whether  from  an  incubator  or  from  a  basket, 
the  less  chance  there  is  for  an  inequitable  temperature. 
When  taken  out  to  be  fed  or  to  have  the  diapers  changed 
or  for  any  other  reason,  the  room  should  be  very  warm  and 
free  from  draughts. 

This  infant  should  not  get  a  bath  in  the  usual  sense  of  the 
word,  but  is  rubbed  instead  with  sweet  oil  once  in  two  or 
three  days,  provided  the  temperature  of  the  room  is  at  least 
80°  F.  It  should  not  wear  the  usual  clothing,  but  may  have 
one  garment,  made  of  cotton  wool  laid  between  two  layers 
of  gauze,  with  sleeves  long  enough  to  come  below  the  finger- 
tips and  a  skirt  that  can  be  pinned  or  sewed  below  the  feet 
without  interfering  with  the  full  extension  of  the  legs.  Noth- 
ing else  should  be  worn  except  the  diapers,  which  are  best 
made  of  a  thick  pad  of  cotton  and  gauze  and  which  are 
not  to  be  pinned  on,  but  simply  laid  in  place  so  that  they 
may  be  changed  very  quickly.  The  infant  should  be  weighed 
in  its  clothing  in  order  to  prevent  exposure.  The  clothes 


THE  PEEMATUEE  INFANT  335 

may  then  be  weighed  and  the  amount  deducted  to  get  the 
actual  weight. 

Proper  Nursing.— If  good  results  are  to  be  expected,  a 
careful  and  conscientious  nurse  who  is  familiar  with  such 
cases  is  absolutely  indispensable.  A  very  small  or  weak 
infant  should  have  two  nurses,  one  for  the  day  and  one 
for  the  night,  who  have  no  other  duties  except  those  of 
watching  and  caring  for  the  infant. 

In  one  of  the  large  amusement  parks  in  this  country 
there  is  a  display  of  incubator  infants,  for  view  of  which 
admission  is  charged,  the  mortality  among  whom  has  proved 
to  be  lower  than  that  of  any  hospital  in  the  country.  This 
is  principally  due  to  the  fact  that  they  have  trained  attend- 
ants whose  sole  work,  year  after  year,  is  taking  care  of 
premature  infants.  Their  thorough  schooling  in  this  one 
branch  of  nursing  has  made  them  very  competent.  The 
average  nurse  has  had  very  little  experience  with  such  in- 
fants and,  if  she  can  be  made  to  realize  this  and  can  be 
taught,  she  will  meet  with  greater  success  in  her  efforts. 

The  Food. — As  in  every  other  disease  of  infancy  the  most 
approved  treatment  of  any  sort  is  without  avail  unless 
the  feedings  are  correct.  There  is  no  question  but  that  the 
premature  infant  is  greatly  handicapped  without  breast  milk. 
The  author  hardly  feels  warranted  in  giving  a  good  prog- 
nosis for  the  very  small  premature  infant  unless  the  mother 
has  breast  milk  or  unless  a  wet  nurse  can  be  obtained.  The 
vast  majority  of  such  infants  have  to  take  the  breast  milk 
from  a  medicine  dropper  for  the  first  few  weeks  at  least,  as 
only  the  most  vigorous  are  able  to  suckle  the  breast  directly. 
Unfortunately,  when  the  infant  is  not  strong  enough  to 
suckle,  the  mother's  breasts  are  apt  to  deteriorate,  although 
pumping  out  the  milk  with  a  breast  pump  will  tend  to  keep 
up  the  flow  for  a  time.  On  the  other  hand,  if  a  wet  nurse 
is  used  her  breast  milk  is  kept  up  in  quality  and  quantity 
by  nursing  her  own  infant.  Very  often,  even  when  breast 


336  SIMPLIFIED  INFANT  FEEDING 

inilk  is  used,  a  sufficient  quantity  is  not  given.  It  is  not 
possible  to  nourish  any  infant  properly  when  only  a  dram 
or  two  of  milk  is  given  once  in  two  hours  or  even  if  given 
every  hour.  If  the  premature  infant  cannot  be  made  to 
take  eight  to  ten  ounces  of  breast  milk  in  twenty-four  hours 
after  the  first  week  of  life,  the  prognosis  is  bad.  The  amount 
of  this  feeding  may  be  very  small  at  first,  but  should  be 
gradually  increased  up  to  one  ounce  or  an  ounce  and  a  half 
every  two  hours.  It  is  not  necessary  to  dilute  the  breast  milk 
unless  it  is  exceptionally  rich  in  fats. 

Breast  milk  can  almost  always  be  obtained  if  sufficient 
effort  is  made  to  do  so.  In  the  large  cities  there  are  wet- 
nurse  agencies,  either  run  by  private  individuals  or  public 
charities.  At  Bellevue  Hospital,  New  York  City,  breast 
milk  is  sold  for  ten  cents  an  ounce  by  mothers  who  have  left 
the  hospital.  The  mothers  are  obliged  to  come  to  the  hos- 
pital to  have  the  milk  pumped  out  of  the  breasts  in  the  pres- 
ence of  a  nurse.  In  small  towns  it  is  often  possible  to  get 
breast  milk  from  some  mother  in  the  community  who  can 
spare  a  few  ounces  each  day  from  her  own  infant.  An  ener- 
getic search  in  the  community  often  results  in  locating 
enough  breast  milk  to  tide  the  premature  infant  over  the 
critical  period  in  the  early  weeks. 

Where  breast  milk  cannot  be  obtained,  the  next  best  food 
is  dry  milk  (see  page  291),  and  the  author  has  had  excellent 
results  with  it  in  feeding  premature  infants. 

Begin  for  the  first  few  days  with  one  teaspoonful  of  dry 
milk  to  one  ounce  of  water  and  give  all  of  this  that  the  infant 
will  take  every  two  hours,  day  and  night.  After  three  days, 
two  teaspoonfuls  to  the  ounce  of  water  may  be  used.  By  the 
end  of  the  first  week  the  food  may  be  used  as  strong  as  one 
level  tablespoonful  of  dry  milk  to  two  ounces  of  water,  even 
though  the  baby  will  not  take  the  whole  two  ounces.  From 
then  on  the  general  rule  for  feeding  dry  milk  will  apply. 
(See  page  295.) 


FOOD  FOE  TRAVELLING  337 

FOOD  FOE  TRAVELLING 

It  is  never  advisable  for  an  infant  to  travel,  but  it  is 
sometimes  unavoidable.  At  such  a  time  the  change  of  milk 
and  the  possibility  of  contamination  make  the  food  question 
a  very  difficult  one,  and  one  made  all  the  more  serious  by 
the  fact  that  the  infant's  digestive  powers  are  often  lowered 
with  the  usual  excitement  incident  to  travel. 

An  excellent  way  to  carry  the  food  is  in  a  travelling  ice- 
box with  a  wicker  cover,  in  which  good  milk,  carefully  pre- 
pared, will  last  for  forty-eight  hours,  if  the  ice  is  replenished. 
Where  this  is  not  practicable,  the  food,  prepared  as  usual 
and  boiled  at  least  ten  minutes  before  the  sugar  is  added, 
should  be  put  into  an  ordinary  preserving  jar  and  sealed  at 
once.  The  jar  must,  of  course,  have  been  boiled  previously, 
together  with  the  cover  and  rubber,  and  ought  to  be  still  hot 
when  the  milk  is  poured  into  it.  This  should  then  be  cooled 
at  once  and  kept  iced  during  the  journey. 

The  Walker-Gordon  laboratories  supply  a  milk  in  any 
strength  which  is  said  to  last  over  a  journey  of  three  weeks' 
duration,  although  it  is  not  guaranteed  for  that  length  of 
time.  This  is  a  refinement  which  is  not  always  possible  for 
people  who  are  too  far  away  from  a  Walker-Gordon  labora- 
tory or  who  have  not  the  means  to  afford  such  a  luxury. 
However,  where  the  facilities  of  these  laboratories  are  avail- 
able, this  is  a  convenient  way  of  supplying  an  infant  with 
its  proper  food  during  a  moderately  long  journey. 

Dry  milk  is  a  very  convenient  food  for  travelling.  It  does 
not  deteriorate  and  may  be  kept  in  a  dry  state  over  a  long 
period  of  time.  It  is  necessary  to  carry  an  alcohol  lamp  or 
a  Sterno  outfit  in  order  to  heat  the  water,  and  the  food  should 
be  made  immediately  before  each  feeding.  Occasionally  it  is 
advisable  to  begin  the  dry  milk  two  or  three  days  preceding 
the  journey  in  order  to  see  whether  it  is  going  to  agree  with 
the  infant.  For  a  journey  involving  only  a  few  days  or  a 
week  it  is  not  necessary  to  add  sugar  or  gruels,  as  dry  milk  m 
22 


338  SIMPLIFIED  INFANT  FEEDING 

itself  is  a  fairly  well-balanced  food.  For  infants  over  two 
or  three  months  of  age,  one  tablespoonf  ul  of  dry  milk  to  one 
ounce  of  water  is  about  the  correct  proportion.  For  further 
information  concerning  dry  milk,  see  page  291. 

WATEB 

The  routine  practice  of  giving  water  to  infants,  the  author 
believes  to  be  very  much  overdone.  Many  begin  the  practice 
at  birth,  before  the  milk  comes  into  the  mother's  breasts, 
by  giving  the  infant  sweetened  water.  Not  only  is  such  a 
procedure  of  no  benefit  to  the  new-born  infant,  but  it  is 
actually  harmful  in  that  it  serves  to  prevent  the  taking  of 
the  breast  after  the  milk  has  come. 

After  the  early  months  of  life,  water  from  the  spoon  is 
useful  as  a  means  of  teaching  the  infant  to  take  nourishment 
in  this  way.  If  this  habit  has  been  acquired  it  will  be  helpful 
during  the  weaning  period,  because  it  accustoms  the  infant 
to  the  cup  and  spoon,  so  that  at  eight  or  ten  months,  when  it 
is  advisable  to  start  giving  food  other  than  the  breast,  the 
infant  will  be  able  to  take  nourishment  more  easily. 

Where  the  breast  milk  is  sufficient  and  no  other  food  is 
needed,  an  infant  may  be  taught  to  take  the  bottle  by  giv- 
ing water  in  it.  Then  if,  at  any  time,  an  occasion  arises 
necessitating  the  absence  of  the  mother,  or  should  she  become 
suddenly  ill,  the  infant  will  take  its  feedings  in  this  way, 
for  an  infant  who  can  take  water  from  the  bottle  will  have 
no  difficulty  in  taking  milk  from  it  when  necessary. 

When  it  is  taken  into  consideration  that  a  bottle  infant 
is  getting  a  quart  or  a  quart  and  a  half  of  liquid  nourishment 
(which  is  over  80  per  cent,  water)  it  is  perfectly  evident  that 
water  is  not  needed  between  feedings  and  the  infant  should 
not  be  forced  to  take  large  quantities  of  it.  If  the  adult 
took  as  much  in  proportion  to  his  weight,  he  would  drink 
from  five  to  eight  gallons  a  day.  The  author  mentions  this 
particularly  because  the  laity  have  the  idea  that  water  is 


LAVAGE  339 

necessary  and  mothers  are  often  greatly  disturbed  when 
it  is  refused. 

Water  never  does  any  harm  if  the  infant  wants  it  except 
in  cases  of  vomiting.  It  is  a  fact  that  certain  breast-fed 
infants  like  water  and  take  a  good  deal  of  it.  Possibly  this 
is  because  the  breast  milk,  although  it  is  sufficient  in  quality, 
is  deficient  in  quantity.  In  this  case  it  does  no  harm  to  give 
water,  but  it  is  best  to  be  on  guard  lest  this  be  a  sign  that 
the  milk  is  not  sufficient  and  water  is  greedily  taken  because 
of  hunger.  To  determine  this  point  one  must  watch  the 
progress  of  the  infant's  nutrition  by  observing  the  weight 
and,  if  it  is  not  gaining  properly,  bottle  feedings  should  be 
added,  instead  of  giving  the  water,  until  the  breast  milk 
can  be  improved. 

In  the  case  of  a  fever  where  there  is  no  vomiting,  plenty 
of  cool  water  should  be  given  in  the  bottle  for  the  purpose  of 
quenching  the  thirst  so  that  the  infant  will  not,  when  thirsty, 
take  more  food  than  it  needs.  The  water  may  be  given  either 
cool  or  warm,  but  most  infants,  with  a  high  temperature, 
prefer  it  cool. 

Water  with  sugar  in  it  should  never  be  given  under  any 
circumstances.  Mothers  and  nurses  are  so  in  the  habit  of 
giving  water  for  all  symptoms  which  may  arise,  such  as  hic- 
cough, colic  and  crying,  that  the  physician  has  to  be  on  his 
guard  lest  it  be  done  without  his  knowledge.  A  bottle-fed 
infant  should  receive  all  its  sugar  in  the  food  itself  and  the 
breast-fed  infant  does  not  need  any  more  sugar  than  the 
amount  contained  in  the  breast  milk.  Many  an  infant  with 
vomiting,  colic  or  loose  stools  will  be  found  to  be  getting 
a  large  amount  of  sugar  in  the  water,  and,  when  this  error  is 
discovered  and  corrected,  the  symptoms  may  cease  at  once. 

LAVAGE  OK  STOMACH  WASHING 

The  process  of  stomach  washing  in  infants  is  a  very 
simple  one,  and  rather  than  being  attended  with  any  danger 


340  SIMPLIFIED  INFANT  FEEDING 

is  more  often  of  decided  benefit  to  the  patient.  It  is  no 
less  effective  in  older  children,  but  their  struggles  against 
having  the  tube  inserted  and  the  necessity  of  using  a  mouth 
gag  often  make  the  process  difficult. 

The  prostration  attending  lavage  is  no  greater  than  that 
of  ordinary  vomiting  and  the  danger  of  misdirecting  the  tube 
into  the  larynx  is  practically  nil. 

The  infant  may  be  lying  on  its  side  or  held  in  an  upright 
position,  its  trunk  slightly  inclined  forward  and  its  arms 
and  entire  body  encased  in  an  improvised  strait- jacket  of 
towelling,  rubber-sheeting  or  something  of  the  sort. 

The  apparatus,  which  should  first  be  sterilized,  consists 
of  a  rubber  catheter  (American  scale  No.  12-16)  connected 
by  a  piece  of  glass  tubing  to  two  feet  of  rubber  tubing  end- 
ing in  a  glass  funnel  (see  illustration,  page  186).  While 
depressing  the  base  of  the  tongue  with  the  left  forefinger, 
the  catheter  is  quickly  passed  into  the  esophagus  with  the 
right  hand.  At  least  ten  inches  of  this  tubing  may  be  passed 
beyond  the  lips.  The  funnel  is  then  held  as  far  as  possible 
above  the  infant's  head  to  allow  any  gases  in  the  stomach 
to  pass  off;  then  it  is  lowered  to  relieve  the  stomach  of 
what  liquid  it  may  contain. 

After  these  preliminaries,  the  funnel  is  again  raised,  and 
two  to  six  ounces  (depending  upon  the  infant's  age  and 
capacity)  of  boiled  water  at  a  temperature  of  from  100°  to 
105°  F.  are  allowed  to  flow  into  the  stomach.  By  lowering 
the  funnel  this  water  will  siphon  out,  bringing  with  it  curds 
and  other  disturbing  factors  from  the  stomach.  The  process 
should  be  repeated  until  the  water  returns  clear — which 
ordinarily  will  require  from  one  to  two  pints.  After  the 
last  siphoning,  the  tube  is  quickly  withdrawn  and  the  patient 
allowed  to  lie  down. 

The  frequency  of  washing  depends,  naturally,  upon  the 
infant's  condition,  although  it  is  rarely  indicated  oftener 
than  once  in  twenty-four  hours. 


IRRIGATING  THE  BOWELS  341 

GAVAGE  OB  FEEDING  BY  TUBE 

The  same  apparatus  is  used  in  gavage  as  in  lavage,  in 
fact  each  feeding  should  be  preceded  by  washing  the  stomach 
in  order  that  residue  in  the  stomach  may  not  interfere  with 
the  proper  digestion  of  the  food  introduced.  The  chief  dif- 
ference is  that  the  infant  must  always  be  in  a  recumbent 
position  and  is  left  so  for  some  time  after  the  process  is 
complete  (see  illustration,  page  216).  The  tube  is  quickly 
passed  down  the  throat  as  in  lavage  and  the  proper  amount 
of  milk  poured  into  the  funnel.  As  soon  as  the  food  reaches 
the  stomach,  the  tubing  is  pinched  together  to  prevent  the 
return  of  the  liquid  and  consequent  choking  and  gagging, 
and  the  catheter  is  quickly  withdrawn. 

This  treatment  has  been  effectively  continued  for  weeks 
without  injuring  the  patient  in  the  least  and  has  moreover 
proved  the  sole  agent  for  maintaining  life  when  other 
methods  of  feeding  were  impossible. 

IRRIGATING  THE  BOWELS 

The  only  apparatus  necessary  for  bowel  irrigations  is 
a  soft  rubber  catheter  (American  scale  No.  16  to  18),  a  glass 
connecting  tube,  a  fountain  syringe  or  an  enamel  or  glass 
irrigation  jar,  and  a  large  douche  pan  (illustration,  see  page 
152).  Two  quarts  of  a  normal  saline  solution  or  plain  tap 
water,  warmed  to  a  temperature  of  100°  F.,  should  be  used. 

The  legs  of  the  infant  are  firmly  clasped  and  held  in  the 
upright  position  and  the  water  should  be  allowed  to  run 
from  the  tube  to  expel  the  air  before  the  tube  is  inserted. 
After  inserting  the  catheter  into  the  rectum,  the  water  is 
turned  on  in  order  to  dilate  the  lower  bowel  so  that  the  prog- 
ress of  the  catheter,  as  it  is  inserted,  may  not  be  obstructed 
by  the  collapsed  gut.  It  is  a  question,  even  with  this  precau- 
tion, whether  the  tube  goes  above  the  sigmoid  flexure,  as 
X-ray  plates,  taken  of  catheters  after  they  have  been  in- 
serted, show  that  they  coil  upon  themselves  instead  of  going 


342  SIMPLIFIED  INFANT  FEEDING 

up  into  the  descending  colon,  as  was  formerly  supposed. 
For  this  reason  the  catheter  should  not  be  inserted  more 
than  six  or  eight  inches  at  the  most.  When  the  bowel  be- 
comes filled  with  water,  the  water  will  run  out  around  the 
tube,  so  that  there  is  no  danger  of  over-distending  the  colon 
by  allowing  too  much  water  in  it  at  any  one  time. 

Bowel  irrigations  have  been  greatly  overdone  and  harm- 
ful results  are  followed  by  their  too  frequent  and  unwar- 
ranted use.  In  severe  cases  of  enteritis,  irrigations,  which 
are  given  every  two  or  three  hours  over  a  prolonged  period 
of  time,  only  act  as  an  irritant.  The  author  has  seen  infants 
with  diarrhoea,  who  have  been  receiving  these  irrigations  for 
two  or  three  weeks,  in  whom  there  is  a  prompt  cessation  of 
the  frequent  loose,  mucous  evacuations  as  soon  as  the  irri- 
gations were  discontinued.  The  practice  of  removing  mucus 
from  the  lower  bowel  is  wrong  if,  as  is  now  supposed,  the 
mucus  is  thrown  out  by  intestinal  mucosa  to  protect  the 
inflamed  gut.  Mucus  is  a  wise  provision  of  nature  and  should 
not  be  interfered  with  by  irrigations  or  any  other  artificial 
means.  Unfortunately,  the  presence  of  a  large  amount  of 
mucus  in  the  water  after  an  irrigation  is  often  wrongly 
interpreted  as  an  indication  for  further  irrigations. 

At  the  beginning  of  an  acute  enteritis,  one  or  two  thor- 
ough irrigations  are  of  great  benefit,  particularly  if  the 
bowels  have  not  been  evacuated  thoroughly.  An  irrigation 
is  also  of  benefit  at  the  beginning  of  an  attack  of  gastro- 
enteritis, where  the  vomiting  is  so  excessive  that  it  is  impos- 
sible to  administer  a  cathartic.  It  may  be  given  to  infants 
and  children  with  a  high  temperature  when  a  gastro-enteric 
cause  is  suspected  and  not  confirmed  by  the  appearance 
of  the  stools  themselves.  Outside  of  these  indications,  irri- 
gations are  better  omitted,  and  are  particularly  contra- 
indicated  when  used  as  a  routine  measure  day  after  day. 


CHAPTER  XXVIII 
NORMAL  DEVELOPMENT   OF  INFANTS 

A  PHYSICIAN  must  familiarize  himself  with  the  normal 
progress  of  an  infant  so  that  he  may  be  able  to  distinguish 
between  the  infant  doing  well  and  the  infant  doing  poorly. 
He  will  be  asked  many  questions  by  anxious  parents  and  he 
should  be  in  a  position  to  answer  them  correctly.  There  is 
only  one  standard, but  there  are  variations  within  the  normal. 

Eyes. — For  the  first  few  days  of  life  the  eyes  of  the 
new-born  infant  should  not  be  exposed  to  too  strong  a  light. 
The  pupils  react  to  light  from  birth  and  within  two  weeks 
after  birth  a  normal  infant  will  follow  light  about  the  room 
and  a  little  later  will  turn  the  head  for  that  purpose.  During 
the  first  three  months  there  is  not  the  proper  coordination, 
and  temporary  strabismus  results.  This  is  often  a  source  of 
great  worry  to  the  mother  if  it  is  not  explained  to  her. 

Ears. — For  the  first  few  days  after  birth  the  new-born 
infant  is  deaf.  This  is  probably  caused  by  the  swelling  of 
the  mucous  membranes  and  the  absence  of  air  from  the 
middle  ear.  After  four  or  five  days,  hearing  is  established 
and  the  child  begins  to  be  sensitive  to  noises  and  is  easily 
disturbed  by  them.  At  the  end  of  two  or  three  months  the 
head  turns  in  the  direction  from  which  sound  comes. 

Touch. — The  sense  of  touch  is  developed  at  birth,  notably 
in  the  lips  and  tongue,  indicated  by  the  infant's  readiness  to 
take  the  breast  and  in  the  normal  act  of  suckling.  Tempera- 
ture is  also  distinguished,  as  shown  by  the  infant  refusing 
its  food  when  too  hot  or  too  cold.  There  is  probably  no  local- 
ization of  sensory  impressions  throughout  the  first  year. 
The  infant  will  cry  from  a  pin  prick,  but  apparently  has  no 
knowledge  of  where  the  pain  comes  from. 

Taste. — The  sense  of  taste  is  highly  developed  at  birth 
and  even  the  new-born  infant  can  distinguish  between  sweet, 

343 


344  SIMPLIFIED  INFANT  FEEDING 

sour  and  bitter.  An  infant  used  to  sweetened  food  will 
refuse  it  when  it  is  unsweetened,  showing  that  the  slightest 
variation  in  the  taste  of  the  food  is  easily  detected.  The 
infant  takes  readily  to  sweet,  and  an  infant  will  take  very 
bitter  substances  when  they  are  combined  with  a  sweet  syrup. 

Smell. — It  is  doubtful  how  soon  the  sense  of  smell  is 
developed.  It  is  known,  however,  that  this  sense  does  not 
develop  as  soon  as  the  other  senses.  The  infant  shows  an 
ability  to  detect  odors  about  the  end  of  the  first  year. 

Sitting  and  Walking. — The  infant  holds  its  head  erect  at 
four  months  of  age,  sits  alone  with  no  support  at  the  back 
at  six  months,  holds  objects  in  its  hands  and  puts  them  to 
the  mouth  between  five  and  six  months  of  age.  At  nine 
months  it  learns  to  creep  if  given  an  opportunity,  and  at 
one  year  should  walk  with  support.  The  age  of  walking 
without  support  varies,  depending  upon  surroundings.  Some 
normal  infants  walk  at  ten  months,  others  not  until  seventeen 
or  eighteen  months.  The  cause  of  delayed  walking  is  usu- 
ally malnutrition,  rickets  or  any  severe  or  prolonged  illness. 

Sitting  alone  and  walking,  besides  many  other  functions, 
indicate  the  infant's  mentality  as  well  as  his  physical  de- 
velopment. If  an  infant  does  not  come  up  to  the  standard, 
this  would  naturally  suggest  either  an  arrestment  of  its 
mental  powers  or  physical  underdevelopment  and  an  exam- 
ination would  be  required. 

Speech. — The  development  of  speech  varies  widely  in  chil- 
dren. At  the  end  of  the  first  year  the  normal  child  usually 
says  one  or  two  words  and,  gradually,  proper  nouns  are 
added  to  the  vocabulary;  then  come  the  names  of  familiar 
objects  and,  at  two  years  of  age,  these  words  are  joined 
together  with  verbs  and  the  infant  learns  to  express  its 
thoughts  in  simple  language. 

Height  and  Weight. — The  normal  infant  should  gain  pro- 
gressively in  weight  and  in  height.  The  increase  in  height 
should  be  about  one  inch  each  month  for  the  first  four  months 


NORMAL  DEVELOPMENT  OF  INFANTS        345 

and  one-half  inch  each  month  after  that  until  the  end  of  the 
first  year.  The  average  infant  is  2Qy2  inches  at  birth  and 
27  inches  at  one  year  of  age.  The  following  table  shows  the 
average  height  as  taken  from  a  number  of  cases : 

Age  Height 

1  month    20%  inches 

2  months    21       inches 

3  months    22       inches 

4  months    23       inches 

5  months    23%  inches 

6  months    24       inches 

7  months    24%  inches 

8  months    25       inches 

9  months    25%  inches 

10  months    26       inches 

11  months    26%  inches 

1  year 27  inches 

2  years  31  inches 

3  years   35  inches 

4  years   37%  inches 

5  years  40  inches 

6  years   43  inches 

7  years  45  inches 

8  years  , 47  inches 

The  height  and  weight  of  an  infant  may  be  dependent 
upon  race  and  climate  and  sometimes  upon  the  size  and 
physique  of  the  parents.  Every  baby,  moderately  fed,  should 
have  a  certain  roundness  characteristic  of  infancy.  The 
following  table  shows  the  average  weight  as  taken  from  a 
number  of  cases : 

1  month  9   Ibs. 

2  months 10y2  Ibs. 

3  months 12   Ibs. 

4  months 13y2  Ibs. 

5  months - .  15   Ibs. 

6  months 16   Ibs. 

7  months 17   Ibs. 

8  months 18   Ibs. 

9  months 19   Ibs. 

10  months 20   Ibs. 

11  months  20%  Iba. 

12  months  .        21   Ibs. 


346  SIMPLIFIED  INFANT  FEEDING 

Extremities. — The  extremities  should  grow  in  proportion 
to  the  body  length.  The  tips  of  the  fingers  should  normally 
extend  to  the  lower  third  of  the  femur.  Both  the  legs  and 
the  arms  should  be  straight,  although  a  slight  bowing  of 
the  legs  is  seen  in  early  infancy.  This  should  straighten  out 
as  the  infant  becomes  older.  An  enlargement  of  the 
epiphyses  is  an  indication  of  rickets. 

Head. — The  head  should  be  round  and  symmetrical.  The 
growth  of  the  head  is  very  rapid  during  the  first  year,  the 
increase  being  about  four  inches  in  circumference.  During 
the  second  year  the  increase  is  about  one  inch.  From  the 
second  to  the  fifth  year  the  growth  is  very  much  slower, 
being  only  about  one  and  one-half  inches  for  three  years. 

Fontanel. — The  anterior  f  ontanel  normally  closes  at  about 
the  eighteenth  month.  It  is  widely  open  at  birth  and  remains 
the  same  size  throughout  the  first  half  of  the  first  year; 
toward  the  end  of  the  first  year  it  should  be  open  widely 
enough  to  admit  the  tip  of  the  finger.  It  gradually  becomes 
smaller  until  at  about  eighteen  months  the  bones  are  united. 

Teeth. — The  two  lower  central  incisors  come  first,  at  six 
or  eight  months ;  the  four  upper  central  incisors,  two  months 
later;  within  the  next  two  months  the  two  lower  lateral 
incisors  appear  on  either  side  of  their  fellows.  Taking  count, 
therefore,  we  have  eight  teeth  at  a  year  or  a  little  later.  At 
fourteen  to  sixteen  months  come  the  four  double  teeth,  and 
at  a  year  and  a  half,  the  canine,  or  eye  and  stomach  teeth, 
come  along  to  fill  in  the  space  that  intervenes,  making  sixteen 
teeth  in  all  at  this  age.  At  two  or  two  and  one-half  years  the 
last  deciduous  teeth  are  erupted,  the  four  second  molars, 
which  complete  the  set  of  temporary  teeth,  twenty  in  all. 


CHAPTER  XXIX 

COW'S  MILK 

Cow 's  MILK,  as  the  cheapest  and  most  satisfactory  substi- 
tute for  the  human  product,  assumes  an  importance  worthy 
of  a  careful  and  an  intelligent  consideration.  Within  recent 
years  the  education  of  the  public,  together  with  the  institu- 
tion and  authorization  of  milk  commissions,  has  been  largely 
instrumental  in  securing  for  the  cities,  particularly,  a  supply 
of  milk  that  is  beyond  reproach  and,  except  in  rare  instances, 
fit  for  use  in  infant  feeding  under  proper  precautions. 

The  free  use  of  ice  in  this  country  has  been  a  large  factor 
in  the  successful  and  superior  system  of  preserving  fresh 
milk,  and  we  are  gradually  learning  that  cleanliness  is  of 
most  vital  importance  in  the  production  and  handling  of 
a  product  so  susceptible  to  contamination  and  bac- 
terial infection. 

Chemical  Composition. — Simply  stated,  all  cow's  milk  con- 
tains fat,  carbohydrates,  proteins,  mineral  matter,  and 
water,  varying  in  quantity  and  proportion  with  the  time  and 
frequency  of  milking,  the  individual  peculiarities,  the  physi- 
cal condition  of  the  cow,  and  the  breed.  A  good  average 
milk  contains  4  per  cent,  fat,  4.5  per  cent,  sugar,  3.5  per  cent, 
protein,  0.75  per  cent,  salts,  and  the  balance,  or  87.75  per 
cent.,  water.  The  proteins  are  mainly  casein  and  albumin 
and  the  chief  salts,  phosphoric  acid,  magnesium,  potassium 
oxide,  chlorine,  and  calcium  and  sodium  oxides.  Fresh  milk 
is  at  first  amphoteric  or  slightly  acid,  but  soon  gives  a  de- 
cided acid  reaction,  which  increases  as  the  milk  ages.  When 
either  strongly  acid  or  decidedly  alkaline  in  its  reaction, 
it  should  be  rejected  as  indicating  excessive  bacterial  growth 
in  one  case  and  the  use  of  preservatives  in  the  other.  In 

347 


348  SIMPLIFIED  INFANT  FEEDING 

general,  cow's  milk  differs  from  human  milk  in  having  a 
greater  opacity,  a  stronger  acid  reaction,  and  more  abundant, 
though  less  soluble,  proteins.  The  fact  that  the  proteins  in 
cow's  milk  are  about  0.5  per  cent,  albuminous  and  3  per  cent, 
casein  (or  curds),  whereas  human  milk  is  1.2  per  cent,  albu- 
min and  0.5  per  cent,  casein,  makes  the  latter  more  digestible 
in  the  infant's  gastro-intestinal  tract.  The  curds  of  human 
milk  are  loose  and  flocculent  and  quickly  dissolved  by  the 
gastric  juices,  while  those  of  cow's  milk  are  hard  and  difficult 
of  digestion.  Human  milk  contains  relatively  few  bacteria 
and  nearly  a  third  less  inorganic  salts,  the  latter  being 
largely  potassium  and  sodium,  while  cow's  milk  consists 
mainly  of  calcium  and  magnesium.  The  kind  of  sugar  in 
both  milks  is  practically  the  same,  so  far  as  chemical  exam- 
ination can  determine,  though  human  milk  contains  about 
7  per  cent.,  as  against  the  4  per  cent,  in  average  cow's  milk. 
The  fats  are  the  most  unstable  element  in  both  milks. 

The  most  minute  chemical  knowledge  of  cow's  milk,  how- 
ever, is  not  of  much  assistance  in  determining  or  affecting 
its  digestibility  in  the  infant's  stomach.  Cow's  milk  was 
intended  for  the  calf,  and  in  order  to  adapt  it  to  the  human 
infant's  digestion  such  measures  of  modification  or  dilution 
as  are  mentioned  elsewhere  in  this  book  must  be  instituted. 

SANITARY  PRODUCTION 

Cleanliness  of  the  stable  and  of  persons  in  any  way  con- 
nected with  dairying  is  imperative.  In  New  York  cement 
construction  is  demanded,  so  that  the  buildings  may  be 
readily  flushed  and  yet  be  impervious  to  moisture.  An  ade- 
quate supply  of  fresh  air  is  required,  and  particular  stress 
is  laid  upon  satisfactory  drainage  and  the  removal  of  all 
excreta  and  rubbish.  Stanchions,  troughs,  and  milking  stools 
must  be  of  metal,  and,  while  side  walls  and  ceiling  may  be  of 
wood,  they  must  be  frequently  whitewashed  or  covered  to 
prevent  the  accumulation  of  dust.  Dust  is  recognized  as 


COW'S  MILK  349 

one  of  the  chief  sources  of  contamination,  and  its  elimination 
does  much  toward  increasing  the  purity  of  the  milk.  The 
fact  that  many  farmers  have  been  in  the  habit  of  feeding 
their  stock  and  sweeping  out  the  barns  at  milking  time  is  one 
reason  why  it  has  been  impossible  to  keep  milk  of  a  really 
superior  quality  uncontaminated. 

No  person  actually  infected  with  disease  or  coming  in 
contact  with  a  disease  in  another  should  be  permitted  in  a 
dairy  or  cow  barn.  The  hands  should  be  carefully  washed 
and  dried  before  each  milking — a  precaution  that  is  not 
always  taken.  Some  light,  easily-washed  clothing  should  be 
worn  during  milking,  preferably  the  white  "dusters,"  which 
can  readily  be  slipped  on  over  the  other  clothing  when  milk- 
ing is  begun. 

The  care  of  the  cow  herself  has  been  reduced  to  a  science. 
In  New  York  a  frequent  inspection  of  the  physical  condition 
of  dairy  cows  is  required.  Where  the  milk  of  but  one  cow  is 
used,  she  should  be  kept  free  from  excitement,  fright,  or 
undue  exercise  that  would  alter  her  milk.  For  this  reason, 
and  because  one  cow's  milk  inevitably  varies,  it  is  highly 
advisable  to  use  milk  from  a  herd, — that  is,  a  mixture  of 
milks  from  several  cows.  In  this  way,  too,  the  danger  of 
transmitting  the  possible  infection  of  one  cow  to  the  con- 
sumer is  greatly  minimized  when  her  milk  is  combined  and 
diluted  with  that  of  several  other  healthy  animals. 

It  may  be  said  here  that  the  milk  of  the  common  or  aver- 
age breed  of  cow  is  preferable  for  ordinary  purposes  to  that 
of  the  highly-bred  animal  whose  milk  is  excessively  rich. 
It  is  not  only  a  fact  that  the  milk  of  the  Guernsey  and  Jersey 
cows  contains  a  very  high  per  cent,  of  fat  (5  per  cent,  or 
ever),  but  the  fat  globules  themselves  are  large  and  there- 
fore not  as  easily  absorbed  in  the  infant 's  enteric  tract.  The 
delicacy  of  the  breed,  too,  renders  them  particularly  prone 
to  disease  and  fluctuating  milk-composition. 

The  animals  should  be  groomed  daily  as  carefully  as  is 


350  SIMPLIFIED  INFANT  FEEDING 

a  horse,  and  just  prior  to  milking  should  have  the  udder, 
tail,  and  belly  wiped  with  a  damp  cloth  and  carefully  dried. 

The  absolute  cleanliness  demanded  in  handling  the  milk 
after  it  leaves  the  cow  is  another  necessary  precaution.  The 
foremilk,  or  that  which  is  milked  out  first,  should  be  dis- 
carded, as  it  invariably  contains  bacteria  which  have  lodged 
in  the  damp  milk-duct  just  inside  the  teat.  The  balance  of 
the  milk  should  be  drawn  off  into  sterile  milk  pails  having  an 
opening  not  exceeding  eight  inches  in  diameter  (in  order  to 
minimize  the  amount  of  contamination  that  can  get  into  the 
pail  itself  during  the  milking),  and  then  put  directly  into 
bottles  of  the  standard  pint  and  quart  size.  Cooling  the 
milk  immediately  and  maintaining  it  at  a  temperature  of 
50°  F.  or  less  is  the  most  important  detail  of  its  preservation. 
The  modern  dairy  has  a  cooler  in  which  the  milk  is  placed 
immediately  after  milking.  It  is  then  bottled  and  packed  in 
ice  and  kept  at  a  low  temperature  until  delivered  to  the  con- 
sumer. Many  dairies  produce  good  milk,  cool  it  immediately, 
and  then  allow  it  to  be  delivered  without  ice>-packing.  In  this 
way,  during  its  delivery,  the  temperature  may  be  raised  to 
60°  or  even  70°  F.  In  the  same  way  the  consumer  often  allows 
milk  to  stand  at  his  door  after  an  early  morning  delivery 
until  the  temperature  has  risen  above  50°  F.,  thus  thwarting 
the  purpose  of  careful  production  and  delivery  that  the 
dealer  intended. 

A  startling  illustration  of  the  results  of  poor  cooling 
came  to  the  author's  attention  recently  in  a  summer  resort. 
He  was  called  to  treat  three  children  in  one  family  who 
became  suddenly  ill  with  a  severe  infectious  diarrho3a.  It 
presently  became  known  that  nearly  every  child  in  the  colony, 
which  was  supplied  by  the  same  milk  dealer,  was  affected 
with  the  same  disorder  in  varying  degrees  of  severity.  Upon 
investigation  it  was  found  that  the  milk,  which  came  from 
another  town,  was  left  in  the  hot  sun  upon  the  station  plat- 
form several  hours  before  delivery,  during  which  time  the 


rnrc 

COW'S  MILK  351 

bacteria  had  ample  opportunity  to  multiply  and  the  milk, 
of  course,  to  outgrow  its  original  purity  and  freshness. 

BACTERIA  IN  MILK 

The  kind  rather  than  the  number  of  bacteria  should  be 
emphasized,  though  a  count  of  10,000  or  less  per  cubic 
centimetre  is  considered  desirably  low. 

The  most  dangerous  bacteria,  naturally,  are  the  patho- 
genic variety,  which  are  responsible  for  the  transmission  of 
tuberculosis  and  summer  diarrhoea,  typhoid,  scarlet  fever, 
and  other  epidemic  diseases  from  the  dairy  or  its  neighbor- 
hood to  the  distant  consumer. 

According  to  Rosenau,  "Milk  is  responsible  for  more 
sickness  and  deaths  than  perhaps  all  other  foods  combined — 
for  several  reasons:  (1)  bacteria  grow  well  in  milk  .  .  .  ; 
(2)  of  all  foodstuffs,  milk  is  the  most  difficult  to  obtain, 
handle,  transport,  and  deliver  in  a  clean,  fresh,  and  satis- 
factory condition;  (3)  it  is  the  most  readily  decomposable 
of  all  our  foods ;  (4)  milk  is  the  only  standard  article  of  diet 
obtained  from  animal  sources  consumed  in  its  raw  state." 
To  quote  again, ' '  Milk  may  .  .  .  contain  more  bacteria 
than  any  other  known  substance ;  it  frequently  contains  many 
more  bacteria  than  are  found  in  sewage"  (Ref.  Rosenau, 
" Preventive  Medicine  and  Hygiene,"  pp.  494  and  510). 
Handling  and  exposure,  naturally,  do  not  reduce  the  number 
of  microorganisms,  and  separator  milk,  or  that  which  has 
been  transferred  from  one  receptacle  to  another,  will  be 
found  to  contain  many  more  bacteria  than  "unmolested" 
milk. 

At  least  8  per  cent,  of  cow's  milk  in  this  country  is  in- 
fected with  tubercle  bacilli,  and  7  per  cent,  of  the  cases  of 
human  tuberculosis  are  directly  attributable  to  a  bovine 
source.  "Pulmonary  tuberculosis  in  man  is  practically 
never  associated  with  the  bovine  bacillus.  Bovine  tubercu- 
losis in  man  is  usually  a  disease  of  the  lymph-glands — the 
lymph-nodes  of  the  cervical  region  and  those  of  the  abdomen 


nO 

VI 0 
352  SIMPLIFIED  INFANT  FEEDING 

being  especially  attacked"  (Rosenau).  For  this  reason,  and 
because  children  drink  so  much  milk,  from  one-third  to  one- 
half  of  the  cases  of  tuberculosis  in  children  are  of  the  bovine 
type.  Pulmonary  tuberculosis,  moreover,  may  be  properly 
distinguished  as  a  class  disease,  while  the  bovine  infection 
attacks  rich  and  poor  alike,  because  of  the  universal  use  of 
milk. 

As  high  as  10  per  cent,  of  the  cases  of  typhoid  in  this 
country  may  be  traced  to  milk,  and  immediately  upon  the 
outbreak  of  an  epidemic  one  of  the  first  points  of  investi- 
gation is  the  milk  supply,  particularly  if  the  trouble  is  limited 
to  one  neighborhood  or  along  one  milk  route. 

Scarlet  fever  from  milk  may  inevitably  be  traced  to  some 
human  source  of  infection.  Carriers  of  the  disease  or 
patients  themselves  have  frequently  been  found  in  dairies 
and  shops,  and  in  some  cities  where  sterilization  of  bottles 
is  not  required  contagion  may  be  directly  traced  to  the  home 
of  the  disease.  Not  only  the  danger  of  the  infected  milk 
must  be  considered,  but  the  high  degree  of  contagion  of  the 
disease  itself,  once  it  is  well  established. 

Diphtheria,  though  more  rarely  a  milk-borne  disease,  is 
attributable  to  the  same  sources  as  scarlet  fever. 

Milk  sickness  and  foot-and-mouth  disease  are  strictly 
bovine  infections  in  man,  but  are  comparatively  rare. 

A  more  recent  and  serious  infection,  due  almost  entirely 
to  cow's  milk,  traceable  either  to  human  sources  or  strepto- 
cocci, is  septic  sore  throat.  In  a  notable  epidemic  in  Boston, 
1911,  studied  by  Winslow,  there  were  20,000  cases*  and  48 
deaths.  In  some  of  these  epidemics  the  mortality  is  very 
high,  and  in  all  of  them  the  morbidity  is  appalling  from 
such  a  source  as  milk. 

In  cities  that  have  no  supervision  of  milk  the  infant 
mortality  is  almost  overwhelming,  whereas  in  the  larger 
cities,  where  the  milk  supply  is  under  careful  supervision 
of  the  Board  of  Health  or  a  medical  milk  commission,  the 


COW'S  MILK  353 

mortality  is  decreasing  each  year.  New  York  City  carries 
one  of  the  lowest  records  for  infant  mortality  in  the  United 
States.  Although  a  high  infant  mortality  might  be  expected 
under  the  conditions  of  overcrowding  and  poor  hygienic  sur- 
roundings, a  comparatively  excellent  standard  of  health  is 
reached,  due,  in  part  at  least,  to  the  careful  supervision  of 
the  milk.  In  fact,  in  the  large  clinics  in  New  York  the  com- 
plaint is  being  made  by  the  internes  and  other  assistants  that 
they  see  too  few  cases  of  diarrhoea  in  the  summer  to  give 
them  sufficient  experience  in  the  subject,  whereas  in  former 
years  the  clinics  were  overcrowded  with  such  cases. 

The  "natural"  bacteria  of  milk  are,  first  and  most  numer- 
ous, the  lactic-acid  bacteria,  almost  immediately  discernible 
in  fresh  milk  and  rapidly  multiplying  until,  if  unaltered, 
they  succeed  in  souring  it  completely.  Chapin  has  estimated 
that  one  bacterium,  if  left  unhampered,  would  multiply 
17,000,000  times  in  twenty-four  hours.  To  maintain  the 
sweetness  of  the  milk,  it  is  desirable  to  reduce  the  number 
of  these  bacteria  and  keep  them  from  multiplying,  although 
in  action  they  have  the  advantage  of  preventing  or  inhibit- 
ing the  growth  and  activity  of  the  more  dangerous  protein- 
destroying  bacteria.  Reasons  are  also  advanced  for  their 
value  in  the  intestine. 

The  decomposing  or  putrefactive  microorganisms,  though 
more  dangerous,  exist  in  unpasteurized  or  unsterilized  milk 
in  a  proportion  not  greater  than  1  to  10  with  the  lactic-acid 
bacteria.  Many  intestinal  disturbances,  particularly  in 
warm  weather,  are  definitely  attributable  to  them,  especially 
if  the  milk  has  been  previously  altered  by  heating.  An  ex- 
cessive number  of  putrefactive  bacteria  would  either  indi- 
cate extremely  bad  sanitary  conditions  in  the  production  or 
handling  of  the  milk  or  else  a  lapse  of  considerable  time  since 
the  production,  heating,  or  boiling  of  the  milk. 

There  is  a  third  variety  of  bacteria,  classified  mainly  as 
the  streptococci,  which  have  apparently  no  effect  upon,  the 

23 


354 

milk  and  whose  action  upon  the  human  organism  has  not 
been  definitely  determined,  although  it  is  known  that  some 
of  the  most  severe  illnesses  of  infancy  are  caused  by  them. 

Beside  the  proper  production  of  milk,  there  are  two  legiti- 
mate methods  of  reducing  the  bacterial  count — pasteurizing 
and  sterilizing — both  of  which  have  their  advantages  and 
drawbacks  and  neither  of  which  obviate  the  necessity  of 
keeping  the  milk  cold  or  comparatively  fresh. 

Pasteurisation  requires  a  constant  temperature  of  about 
160°  F.  for  at  least  twenty  minutes,  during  which  process  all 
the  non-spore-bearing  bacteria  are  destroyed  without  radi- 
cally altering  the  taste  of  the  milk.  If  immediately  cooled 
and  used  before  it  has  a  chance  of  being  further  contam- 
inated, this  is  an  eminently  safe  milk  to  use.  However,  if  it 
is  recontaminated,  the  powers  of  the  milk  itself  to  reduce  the 
danger  of  the  attacking  bacteria  by  inhibition  have  been  re- 
moved through  heating,  and,  while  the  milk  will  not  sour 
so  readily,  it  becomes  infected  with  a  dangerous  variety  of 
bacteria.  The  process  of  pasteurization  is  a  more  or  less 
difficult  one  to  perform  successfully  and  requires  rather 
expensive  equipment. 

There  is  a  brief  treatment  of  milk,  improperly  called 
"commercial"  pasteurization,  which  consists  of  a  short  ex- 
posure (not  more  than  from  thirty  to  sixty  seconds)  to 
a  temperature  of  160°  P.  This  succeeds  in  killing  some  of 
the  bacteria,  but  the  milk  should  be  immediately  and  hy- 
gienically  bottled  and  cooled  to  avoid  the  dangers  of 
recontamination.  This  method  of  pasteurization  is  not  to 
be  recommended. 

Sterilization  means  simply  boiling  (212°  F.)  for  varying 
lengths  of  time  sufficient  to  destroy  all  microorganisms.  It 
has  the  advantage  of  being  simple,  easy,  and  effective,  but 
changes  the  taste  of  the  milk  markedly.  It  is  advisable  in 
very  hot  weather  or  when  the  milk  has  come  from  a  decidedly 
questionable  source,  or  in  neighborhoods  where  the  people 
are  ignorant  or  have  not  the  actual  facilities  for  keeping  raw 


COW'S  MILK  355 

milk  fresh.    The  value  of  boiled  milk  aside  from  the  action 
of  the  heat  upon  the  bacteria  is  discussed  elsewhere. 

It  must  be  remembered  that  neither  of  these  methods 
destroys  the  spore  of  the  bacteria,  which  will  survive  almost 
indefinitely  and  germinate  at  the  least  rise  of  temperature. 
It  is  unfortunate  that  in  this  reinhabitation  the  putrefactive 
bacteria  exceed  the  lactic  organisms,  so  that,  while  the  milk 
does  not  show  the  natural  evidences  of  staleness,  it  is  much 
more  dangerous  when  improperly  kept  and  cared  for. 

ADULTERATION  OF  MELK 

Under  the  careful  supervision  which  milk  now  receives, 
the  danger  of  adulteration  is  greatly  reduced.  The  addi- 
tion of  cream  to  raise  the  percentage  of  the  milk,  though 
unusual,  is  not  harmful.  Neither  is  the  addition  of  pure 
water,  though  this  practice  is  no  longer  general  under  the 
specific  standards  of  quality. 

The  following  are  the  kinds  of  adulteration  forbidden  in 
New  York  as  taken  from  the  sanitary  code  of  the  City 
of  New  York: 

First — Milk  containing  more  than  eighty-eight  and  one- 
half  per  centum  of  water  or  fluids. 

Second — Milk  containing  less  than  eleven  and  one-half 
per  centum  of  milk  solids. 

Third — Milk  containing  less  than  eight  and  one-half  per 
centum  of  solids  not  fat. 

Fourth — Milk  from  which  any  part  of  the  cream  has  been 
removed. 

Fifth — Milk  containing  less  than  three  per  centum  of  fats. 

Sixth — Cream  which  contains  less  than  eighteen  per 
centum  of  butter  fat. 

Seventh — Milk,  or  cream  from  milk  which  has  been  drawn 
from  animals  within  fifteen  days  before,  or  five  days  after 
parturition. 

Eighth — Milk,  or  cream  from  milk  which  has  been  drawn 
from  animals  fed  on  distillery  waste,  or  any  substance  in  a 
state  of  putrefaction,  or  on  any  unwholesome  food. 


356 


SIMPLIFIED  INFANT  FEEDING 


REGULATIONS   GOVERNING  THE  GRADES  AND  DESIGNATION 

NEW 

The  following   classifications  apply  to   milk  and  cream.     The   regulations 


Grades  of 

milk  or 

Tuberculin  test 

cream  which 
may  be  sold 

Definition 

and  physical 
condition 

Bacterial  contents 

in  the  city  of 

New  York 

1.  Only  such 

cows    shall    be 

admitted  to  the 

herd  as  have  not 

reacted  to  a  di- 

GBADB A 

Milk  or  cream 
(Raw) 

Grade  A  milk  or  cream 
(raw)   is  milk  or  cream 
produced  and  handled  in 
accordance  with  the  mini- 
mum requirements,  rules 
and  regulations  as  herein 
set  forth. 

agnostic    injec- 
tion of  tubercu- 
lin  and  are  in 
good     physical 
condition. 
2.  All     cows 
shall  be  tested 
annually     with 

Grade  A  milk  (raw)   shall  not 
contain   more   than   60,000  bac- 
teria  per   c.c.   and    cream   more 
than    300,000    bacteria    per  c.c. 
when  delivered  to  the  consumer 
or  at  any  time  prior  to  suoh  de- 
livery. 

tuberculin    and 

all  reacting  ani- 

mals shall  be  ex- 

cluded from  the 

herd. 

Grade    A    milk    (pasteurized) 

Grade  A  milk  or  cream 

shall  not  contain  more  than  30,- 

(pasteurized)   is  milk  or 

No  tuberculin 

000  bacteria  per  c.c.  and  cream 

cream  handled  and  sold 

test  required  , 

(pasteurized)  more  than  150,000 

by  dealers  holding  permits 

Out  cows  must 

bacteria  per  c.c.  when  delivered 

Milk  or  cream 

therefor  from  the  Board 

be    healthy    as 

to  the  consumer  or  at  any  time 

(Pasteurized) 

of  Health,  and  produced 

disclosed    by 

after  pasteurization  and  prior  to 

and   handled  in   accord- 

physical exami- 

such delivery. 

ance    with    the    require- 

nation    made 

No  milk  supply  averaging  more 

ments,  rules  and  regula- 

annually. 

than    200,000    bacteria    per    c.c. 

tions  as  herein  set  forth. 

shall  be  pasteurized  for  sale  under 

this  designation. 

No  milk  under  this  grade  shall 

contain  more  than  100,000  bac- 

Grade B  milk  or  cream 

teria  per  c.c.  and  no  cream  shall 

(pasteurized)  is  milk  or 

contain  more  than  500,000  bac- 

GRADE B 

Milk  or  cream 
(Pasteurized) 

cream      produced      and 
handled    in    accordance 
with    the    minimum    re- 
quirements,     rules     and 
regulations      herein      set 
forth  and  which  has  been 
pasteurized  in  accordance 
with     the     requirements 
and  rules  and  regulations 

No  tuberculin 
test  required, 
but  cows  must 
be    healthy    as 
disclosed    by 
physical  exami- 
nation      made 
annually. 

teria  per  c.c.  when  delivered  to 
the  consumer  or  at  any  time  after 
pasteurization  and  prior  to  euch 
delivery. 
No  milk  supply  averaging  more 
than  1,500,000   bacteria   per  c.c. 
shall  be  pasteurized  in  this  city 
for  sale  under  this  designation. 
No  milk  supply  averaging  more 

of    the    Department    of 

than    300,000    bacteria    per    c.c. 

Health  for  pasteurization. 

shall   be   pasteurized   outside  _of 

this  city  for  sale  under  this  desig- 

nation. 

Grade  C  milk  or  cream 
is  milk  or  cream  not  con- 

GBADB C 

forming  to  the   require- 

No tuberculin 

ments  of  any  of  the  sub- 

test required, 

No   milk   of   this   grade   shall 

Milk  or  cream 

divisions  of  Grade  A  or 

but  cows  must 

contain  more  than  300,000  bac- 

(Pasteurized) 

Grade  B  and  which  has 

be    healthy    as 

teria   per   c.o.  and   no  cream  of 

(For    cooking 

been  pasteurized  accord- 

disclosed       by 

this    grade    shall    contain    more 

and    manu- 

ing to  the  requirements 

physical  exami- 

than 1,500,000  bacteria  per  c.c. 

facturing  pur- 
poses only). 

and  rules  and  regulations 
of  the  Board  of  Health  or 

nation     made 
annually. 

after  pasteurization. 

boiled  for  at  least  two  (2) 

minutes. 

NOTE. — Sour  milk,  buttermilk,  sour  cream,  kumyss,  matzoon,  zoolac  and  similar 
•ad  shall  be  pasteurized  before  being  put  through  the  process  of  souring.  Sour  cream  shall 

No  other  words  than  those  designated  herein  shall  appear  on  the  label  of  any  container 
authorized  under  the  State  laws. 


COW'S  MILK 


357 


OF  MILK  AND  CREAM  WHICH  MAY  BE  SOLD  IN  THE  CITY  OF 
YORK. 

regarding  bacterial  content  and  time  of  delivery  shall  not  apply  to  sour  cream. 


Necessary 

scores  for 
dairies 

Time  of 
delivery 

Bottling 

Labeling 

Pasteurisation 

producing 

Unless 

otherwise 

specified  in 

Equip.  25 

Shall  be 
delivered 

the  permit 
this  milk  or 

Outer  caps  of  bottles  shall  be 
white  and  shall  contain  the  words 

Meth.  50 

within  36 

cream  shall 

Grade  A,  Raw,  in  black  letters 

Total  75 

hours  after 
production. 

be  delivered 
to  the  c  o  n  - 

in  large  type,  and  shall  state  the 
name  and  address  of  the  dealer. 

sumer  only  in 

bottles. 

Equip.  25 
Meth.  43 
Total  68 

Shall    be 
delivered 
within    36 
hours      after 
pasteuri- 
zation. 

U  n  I  e  B  s 
otherwise 
specified  in 
the  permit 
this  milk  or 
cream  shall 
be  delivered 
to  the  con- 
sumer only  in 

Outer  caps  of  bottles  shall  be 
white  and  shall  contain  the 
words  Grade  A  in  black  letters  in 
large  type,  date  and  hours  be- 
tween wnich  pasteurization  was 
completed;  place  where  pasteuri- 
zation was  performed;  name  of 
the  person,  firm  or  corporation 
offering  for  sale,  selling  or  deliver- 

Only such 
milk  or  cream 
shall   be  re- 
garded as  pas- 
teurised aa  baa 
been  subjected 
to  a  tempera- 
ture averaging 
145°  Fahr.  for 
not   less   than 

bottles. 

ing  same. 

30  minutes. 

Outer  caps  of  bottles  contain- 

ing milk  and  tags  affixed  to  cans 

containing  milk  or  cream  shall  be 

white  and  marked  "Grade  B" 

in  bright  green  letters  in  large 

Only   such 

Equip.  20 
Meth.  35 

Milk  shall 
be  delivered 
within  36 
hours  and 

May  be  de- 
livered in  cans 

type,  date  pasteurization  was 
completed,  place  where  pasteur- 
ization was  performed,  name  of 
the  person,  firm  or  corporation 
offering  for  sale,  selling  or  deliv- 

milk or  cream 
shall  be  re- 
garded as  pas- 
teurized as  has 
been  subjected 

Total  55 

cream  with- 
in 48  hours 

or  bottles. 

ering  same.  Bottles  containing 
cream  shall  be  labeled  with  caps 

to  a  tempera- 
ture averaging 

aft  er  p  aa  - 
teurization. 

marked  "Grade  B"  in  bright 
green  letters,  in  large  type,  and 
shall  give  the  place  and  date  of 

145°  Fahr.  for 
not  less   than 
30  minutes. 

bottling  and  shall  give  the  name 

of  person,  firm  or  Corporation 

offering  for  sale,  selling  or  deliv- 

ering same. 

Only     such 

milk  or  cream 

Tags  affixed  to  cans  shall  be 

shall     be     re- 

Score 40 

Shall  be 
delivered 
within  48 
hours  after 
pasteuri- 
zation. 

May  be  de- 
livered in  cans 
only. 

white  and  shall  be  marked  in  red 
with  the  words  "Grade  C"  in 
large  type  and  "for  cooking"  in 
plainly  visible  type,  and  cans 
shall  have  properly  sealed  metal 
collars,  painted  red  on  necks. 

garded  as  pas- 
teurized as  has 
been  subjected 
to  a  tempera- 
ture averaging 
145°  Fahr.  for 

not  less   than 

30  minutes. 

products  shall  not  be  made  from  any  milk  of  a  less  grade  than  that  designated  for  "Grade  B" 
not  contain  a  lesa  percentage  of  fats  than  that  designated  for  cream, 
containing    milk  or  cream  or  milk  or  cream  products  except  the  word      ceruti 

358  SIMPLIFIED  INFANT  FEEDING 

Ninth — Milk,  or  cream,  from  milk  which  has  been  drawn 
from  cows  kept  in  a  crowded  or  unhealthy  condition. 

Tenth — Milk,  or  cream  which  has  been  diluted  with  water 
or  any  other  fluid,  or  to  which  has  been  added,  or  into  which 
has  been  introduced  any  foreign  substance  whatever. 

Eleventh — Milk  or  cream,  the  temperature  of  which  is 
higher  than  50  degrees  Fahrenheit,  or  which  contains  an 
excessive  number  of  bacteria.  This  requirement  includes 
" Grade  C  Milk"  after  pasteurization. 

Twelfth — Milk  or  cream  which  is  produced  in  violation 
of  the  rules  and  regulations  adopted  by  the  Board  of  Health. 

The  most  dangerous  adulteration  is  the  use  of  preserva- 
tives, most  commonly  formaldehyde,  borax,  boric  acid,  and 
sodium  bicarbonate.  The  danger  lies  not  so  much  in  the 
chemicals  themselves,  which,  though  harmful,  are  highly 
diluted,  as  in  the  original  condition  of  the  milk  that  would 
require  such  "doctoring."  Their  presence  can  usually  be 
assured  by  the  inability  of  the  milk  to  sour  or  change  nor- 
mally with  age. 

Grades  of  Milk. — The  sale  of  the  offensive  "  grocery"  milk 
or  that  which  is  doled  out  from  cans  in  ofttimes  dirty  shops 
is  being  gradually,  and  in  some  places  entirely,  abolished. 
It  is  a  grade  of  milk  the  cheapness  of  which  prevents  the 
care  in  production  and  transportation  necessary  for  its  suc- 
cessful preservation  or  initial  cleanliness. 

The  best  milk  procurable  is  ' '  certified, ' '  or,  as  the  name 
implies,  milk  guaranteed  to  be  of  the  highest  uniform  quality 
produced  under  the  best  conditions  of  health  and  cleanliness 
with  the  supervision  of  a  medical  milk  commission. 

Next  in  quality  to  certified  milk  is  inspected  milk,  which 
in  New  York  has  three  grades,  A,  B  and  C.  On  pages  276  and 
277  are  excerpts  from  the  Rules  and  Regulations  of  the  New 
York  Board  of  Health  illustrating  this  grading  and  the  pre- 
cautions taken  to  protect  the  public.  No  uninspected  milk  or 
a  grade  lower  than  C  is  procurable  within  the  city. 


COW'S  MILE  359 

RULES    AND   REGULATIONS    FOR   THE    SALE  OF    DIPPED    MILK    AND 
CREAM  IN  STORES  IN  THE  CITY  OF  NEW  YORK 

1.  Milk  or  cream  shall  not  be  handled  or  sold  in  any 
room  which  is  unduly  crowded  with  goods,  wares  or  mer- 
chandise. 

2.  Milk  or  cream  shall  not  be  dipped  from  cans  stored 
in  a  room  in  which  butter  or  cheese  is  manufactured. 

3.  Milk  or  cream  must  be  stored  in  a  cooling  or  refrigerat- 
ing room,  or  ice  chest,  the  construction  of  which  has  been 
approved  by  the  Department  of  Health. 

4.  Milk  or  cream  shall  not  be  dipped  from  cans  stored  in 
a  milk  booth. 

5.  Milk  shall  be  kept  at  a  temperature  of  50  degrees 
Fahrenheit,  or  below,  at  all  times. 

Equipment 

1.  Booms  in  which  milk  or  cream  is  handled  or  sold  shall 
be  well  lighted. 

2.  The  floors,  walls,  and  ceilings  shall  be  smooth  and 
must  be  kept  clean  and  sanitary. 

3.  All  windows  and  doors  shall  be  properly  screened. 

4.  An  adequate  supply  of  hot  water  shall  be  provided 
for  the  washing  of  utensils. 

5.  A  sufficient  number  of  properly  constructed  ice  tubs, 
or  other  adequate  refrigerating  facilities,  for  cans  of  milk  or 
cream  shall  be  provided. 

6.  All  utensils  used  for  dipping  milk  or  cream  shall  be 
of  the  seamless  sanitary  type,  heavily  tinned. 

Methods 

1.  No  milk  or  cream  shall  be  dipped  from  cans  stored  in 
any  room  in  which  rubbish  or  dirty  material  is  allowed  to 
accumulate,  or  in  which  there  are  offensive  odors. 

2.  All  cans  or  other  receptacles  used  for  milk  or  cream 
shall  be  cleansed  thoroughly  immediately  upon  emptying. 


360  SIMPLIFIED  INFANT  FEEDING 

3.  The  cans  from  which  milk  or  cream  is  dipped  shall  be 
packed  in  ice,  and  shall  be  kept  covered  as  much  as  possible 
at  all  times. 

4.  The  ice-tubs  in  which  milk  or  cream  is  stored  shall  be 
painted  inside  and  outside  and  shall  be  kept  clean  at  all  times. 

5.  A  separate  dipper  shall  be  provided  for  each  can  from 
which  the  supply  is  being  served,  and  such  dipper  shall 
remain  in  the  can  between  dippings  until  all  the  milk  in  the 
can  has  been  disposed  of. 

6.  All  dippers,  measures,  or  other  utensils  used  in  the 
handling  of  milk,  condensed  milk,  or  cream  must  be  kept 
clean  while  in  use,  and  must  be  thoroughly  cleaned  with  hot 
water  and  soda  (sodium  carbonate)  and  then  with  boiling 
water  directly  after  each  day's  use. 

7.  All  goods  sold  in  milk  stores  must  be  either  in  un- 
broken packages,  or  must  be   so   placed,   protected,    and 
handled  that  no  dust  or  odors  therefrom  can  injuriously 
affect  the  milk. 

8.  Dry  sweeping  and  dusting  in  rooms  in  which  milk  or 
cream  is  dispensed  is  prohibited. 

9.  The  tags  on  cans  of  milk  or  cream  must  be  kept  on  file 
in  the  store  for  at  least  two  months,  for  inspection  by  the 
Department  of  Health. 

10.  The  attendants   shall  wear  clean,   washable   outer 
clothing. 

11.  Only  such  persons  shall  be  employed  as  are  free  from 
infectious  disease  which  may  be  transmitted  in  the  handling 
of  milk. 


CHAPTER  XXX 

PROPRIETARY  FOODS 

THE  extensive  use  of  the  various  proprietary  foods 
throughout  the  country  makes  it  necessary  for  the  physician 
to  know  what  each  one  contains  and  the  proper  way  to  use  it. 

Many  of  these  foods  are  made  up  of  ingredients  which 
may  be  properly  used  with  benefit  to  the  individual  infant — 
if  the  physician  does  not  object  to  the  use  of  a  food  that 
is  advertised  to  the  laity.  However,  these  foods  should 
be  intelligently  used  and  not  merely  according  to  a  set 
of  general  formulas  which  the  manufacturer  prepares.  In 
other  words,  the  physician  should  be  equipped  with  a  suffi- 
cient understanding  of  infant  feeding  to  construct  each 
formula  to  suit  the  needs  of  the  individual  patient.  If, 
for  instance,  a  food  is  used  that  is  composed  of  malt 
sugar,  a  sufficient  knowledge  of  infant  feeding  would  indi- 
eate  the  exact  amount  of  milk  and  water  necessary  to  be 
added  to  this  food. 

The  remaining  portion  of  this  chapter  will  be  devoted  to 
a  description  of  many  of  the  foods  that  are  used  in  this  coun- 
try, so  that  the  physician  may  know  what  his  patients  are 
getting  when  they  come  to  him  having  already  been  fed  with 
a  proprietary  food,  or  he  may  direct  the  use  of  such  foods 
if  it  is  desired  to  continue  them. 

THE  "ALLENBURYS'  "  INFANTS'  FOODS 
Made  by  the  Allen  &  Hanburys  Company 
There  is  a  series  of  these  foods,  Nos.  1,  2  and  3. 
Name.— The  "  Allenburys '  "  Milk  Food  No.  1  (for  use 
from  birth  to  three  months  of  age). 

Ingredients.— Dried   milk   and   cream,   and  milk   sugar 

361 


362  SIMPLIFIED  INFANT  FEEDING 

(66  -f  per  cent.).  Fresh  cow's  milk  is  modified  to  imitate 
the  percentages  of  breast  milk  by  adding  cream  and  milk 
sugar.  It  is  then  evaporated  in  vacuo  and  sold  in  pow- 
der form. 

How  Used. — From  one-quarter  to  one-half  ounce  of  the 
powder  is  added  to  from  three  to  four  and  a  half  ounces  of 
water.  Occasionally  addition  of  1  dram  of  separated  cream 
is  recommended. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Moisture 1.82 

Carbohydrates  (soluble  in  water) 66.61 

Carbohydrates  (insoluble  starch) 0.00 

Soluble  nitrogenous  matter    (calculated   as 

albumin) 10.70 

Milk  fat 16.79 

Soluble  mineral  matter * 4.08 

Analysis  of  Food  as  Prepared  for  Infant's  Consumption. — 

Per  cent. 

Fat 3.33 

Casein 1.12 

Albumin 1.00 

Carbohydrates 10.20 

Mineral  matters 0.67 

Water 83.68 

Caloric  Value.— 81.47  per  ounce. 

Price  and  Size  of  Package. —  Small  size,  12  ounces,  retail- 
ing from  33  cents  to  50  cents;  large  size,  24  ounces,  varies 
from  75  cents  to  $1. 

Name.— The  "  Allenburys '  "  Milk  Food  No.  2  (for  use 
from  three  to  six  months  of  age). 

Ingredients. — The  same  as  No.  1,  "with  the  addition  of 
a  small  amount  of  maltose,  dextrin,  soluble  phosphates,  and 
albuminoids."  The  mixtures  are  stronger,  the  maltose  and 


PROPRIETARY  FOODS  363 

dextrin  being  converted  from  crushed  whole  wheat  with  the 
addition  of  malt  wort. 

How  Used. — Like  No.  1,  except  that  stronger  mixtures 
are  made. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Moisture 2.24 

Carbohydrates  (soluble  in  water) 68.78 

Carbohydrates  (insoluble  starch) 0.00 

Soluble  nitrogenous   matter    (calculated  as 

albumin)   10.23 

Milk  fat 14.94 

Soluble  mineral  matter 3.81 

Caloric  Value.— 80.40. 

Price  and  Size  of  Package. — Same  as  No.  1. 
Name.— The  "Allenburys'  "  Malted  Food  No.  3  (for  use 
from  six  months  upward). 

Ingredients. — "  Cooked  wheaten  flour   (insoluble  starch, 
60  per  cent.)  and  the  active  and  nutritive  constituents  of  pure 
malt."    Cooked  wheaten  flour  is  acted  upon  by  malt  and 
partially  dextrinized  into  dextrin  and  maltose. 
How  Used. — As  a  diluent  for  cow's  milk. 
Analysis  of  Food  as  Sold. — 

Per  cent. 

Moisture 3.00 

Carbohydrates  (soluble  in  water) 14.51 

Carbohydrates  (insoluble  starch) 60.01 

Soluble  nitrogenous   matter   (calculated  as 

albumin) 10.23 

Milk  fat 1.05 

Soluble  mineral  matter 60 

Price  and  Size  of  Package. — Small  size,  12  ounces,  retail- 
ing from  24  cents  to  30  cents ;  large  size,  25  ounces,  from  50 
cents  to  60  cents. 


364  SIMPLIFIED  INFANT  FEEDING 

BABIES*  FOOD 
Made  by  the  Health  Food  Company 

Ingredients. — Wheat  and  barley  flour.  The  wheat  and 
barley  are  sterilized  and  ground  into  a  fine  powder,  29  per 
cent,  of  the  starch  meanwhile  being  changed  into  dextrin  by 
a  process  not  described  in  the  manufacturer's  literature. 

How  Used. — The  food  is  prepared  for  use  with  sweet  milk 
and  cream,  granulated  sugar  and  salt. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Water 4.51 

Fat 1.18 

Proteins 15.31 

Carbohydrates 78.10 

Ash  (phosphates) 90 

Caloric  Value. — Not  given. 

Price  and  Size  of  Package. — Sold  in  fifty-cent  cans  which 
contain  one  pound. 

BENGER'S  FOOD 
Made  by  Benger's  Food,  Ltd. 

Ingredients. — Baked  wheat  flour,  pancreatic  extract.  The 
wheat  flour  is  baked  in  vacuo  to  thoroughly  break  up  the 
starch  granules,  and  pancreatic  extract  is  added  to  it. 

How  Used. — The  powder  (in  which  form  the  food  is  sold) 
is  made  into  a  smooth  paste  with  cold,  fresh  milk.  To  this 
boiling  milk  and  water  are  added  and  the  whole  set  aside 
to  cool,  during  which  time  the  pancreatic  extract  acts  upon 
the  starch,  changing  part  of  it  into  dextrin  and  maltose  (92 
per  cent,  dextrin  and  maltose  in  thirty  minutes)  and  par- 
tially pancreatizing  the  milk.  The  process  is  completed 
by  boiling  the  mixture. 


PROPRIETARY  FOODS  365 

Analysis  of  Food  as  Sold. — 
Fat 919 

f  Dextrins  and  sugars . .     3.337  1 
Carbohydrates  -<  Starch 77.023  >       80.652 

(  Cellulose 292  J 

Proteins 12.187 

Mineral  matter 969 

Moisture  .  5.273 


100.000 

Analysis  of  Food  as  Prepared  for  Infants'  Consumption 
(when  made  with  equal  parts  of  milk  and  water, and' thirty 
minutes  allowed  for  digestion). — 

Fat 1.89 

C  Lactose 2.35  \ 

Sugars  <  Dextrins  2.00  V 5.65 

(Maltose 1.30  ) 

Starch 50 

Protein 2.32 

Mineral  matter  .  .43 


Total  solids 10.79 

Caloric  Value  (in  powder  form). — 110.5  per  ounce 
(average). 

Price  and  Size  of  Package. — 4  ounces,  25  cents ;  12  ounces, 
60  cents ;  3y2  Ibs.,  $1.75. 

CARNRICK'S  LACTO  PREPAKATA 
Made  by  Reed  and  Carnrick 

Ingredients. — Dried  rnilk  (from  which  the  fatty  acids 
are  removed  and  replaced  by  cocoa  butter),  pancreatic  ex- 
tract, and  milk  sugar  (63  per  cent.).  The  fatty  acids  of  the 
milk  are  removed  and  replaced  with  cocoa  butter.  The  milk 
is  then  treated  with  fresh  extract  of  pancreas,  and,  after 


366  SIMPLIFIED  INFANT  FEEDING 

the  proper  amount  of  predigestion,  pure  milk  sugar  is  added 
and  the  milk  dried  in  vacuo. 

How  Used. — Add  sufficient  water  to  the  powder  to  replace 
that  taken  out  by  evaporation.  The  food  ' '  requires  no  addi- 
tion of  milk  or  other  food  substances. ' ' 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Fats 12.35 

Proteids   14.51 

Soluble  carbohydrates 63.68 

Insoluble  carbohydrates 00.00 

Inorganic  salts  3.66 

Moisture 5.80 

Analysis  of  Food  as  Prepared  for  Infant  Consumption.— 
Not  given. 

Caloric  Value. — 21.78  per  ounce. 

Price  and  Size  of  Package. — i/^-pound  package,  50  cents; 
1-pound  package,  $1 ;  5-pound  package,  $4. 

HTJBBKLL'S  PBJEPAKED  WHEAT 
Sold  by  Llewellyn's  Drug  Store,  Philadelphia 

Ingredients. — Wheat  flour  baked  at  a  temperature  of 
230°  F.  for  twelve  hours. 

How  Used. — With  milk  according  to  formula. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Proteids 11 

Fat 1 

Carbohydrates  74 

Salts 4 

Water 12 

Caloric  Value. — 106  calories  per  avoirdupois  ounce. 
Price  and  Size  of  Package. — One  size,  14  ounces,  50  cents. 


PROPRIETARY  FOODS  367 

ESKAY'S  FOOD 
Made  by  Smith,  Kline  &  French  Company 

Ingredients. — Barley,  wheat,  oats,  milk  sugar  (54  per 
cent.) ,  a  small  quantity  of  whole  egg  and  inorganic  salts.  The 
barley,  wheat,  and  oats  are  thoroughly  baked  at  a  high  tem- 
perature in  order  to  rupture  all  the  starch  granules,  and  the 
sugar  of  milk  and  whole  egg  are  used  added. 

How  Used. — With  fresh  cow's  milk  or  with  top  milks. 

Analysis  of  Food  as  Prepared  for  Infants'  Use. — 

Fat,  Proteids,    Milk  sugar.        Salts,          Starch, 

Per  cent.        Per  cent.       Per  cent.      Per  cent.     Per  cent. 

Eskay's  Food  (regu- 
lation formula  at 
six  months  with 
cow's  milk) 3.00  2.50  5.00  0.50  1.25 

Top  milk  formula  at 

sixth  month 4.00  1.75  4.75  0.50  1.25 

Eskay's  Food  contains,  as  prepared  by  the  various  for- 
mulas, about  4  per  cent,  of  Eskay's  Food,  or  one  and  a  third 
tablespoonfuls  to  the  pint  of  mixture.  The  prepared  food 
contains  only  1.25  per  cent,  starch. 

Analysis  of  Food  as  Sold   (La  Wall).— 

Per  cent. 

Fat 3.52 

Proteids 6.70 

Milk  sugar 54.12 

Starch  (disrupted  grains) 29.90 

Dextrin,  etc 

Fibre ."....  1-30 

Ash 

Moisture  . . . . « 1-70 

99.93 
Caloric  Value  (dry).— 120  calories  per  ounce. 


368  ,  SIMPLIFIED  INFANT  FEEDING 

Price  and  Size  of  Package. — 31^-ounce,  25  cents;  8-ounce, 
50  cents ;  16-ounce,  75  cents ;  68-ounce,  $2.50. 

MUEDOCK'S  LIQUID  FOOD 
Made  by  the  Murdock  Liquid  Company 

Ingredients. — "Raw  preparation  of  beef,  mutton,  and 
fruits,  preserved  with  10  per  cent,  by  volume  of  alcohol. ' ' 

How  Used. — In  addition  to  the  regular  feeding,  though 
not  as  a  diluent. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Albumin 11.10 

Albuminoids 16.28 

"Free  from  insoluble  matter." 
Caloric  Value. — Not  given. 

Price  and  Size  of  Package. — 5^  fluidounces,  55  cents;  11 
fluidounces,  $1. 

IMPERIAL  GRANUM  FOOD 
Made  by  the  Imperial  Granum  Company 

Ingredients. — Wheat  flour  slightly  dextrinized  by  a  special 
process  during  which  the  raw  starch  is  cooked  (amount  of 
dextrin  and  dextrose  not  given).  iStarch,  73.54  per  cent. 

How  Used. — As  an  adjuvant  to  milk  and  water. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Moisture 6.04 

Ash 49 

Fat 72 

Carbohydrates 76.60 

Total  albuminoids 13.77 

Analysis  of  Food  as  Prepared  (with  milk)  for  Infants'  Con- 
sumption.— Not  given,  as  it  varies  with  formulas  used. 
Caloric  Value. — About  117  calories  per  ounce. 


PROPRIETARY  FOODS  369 

Price  and  Size  of  Package.— Four  sizes,  from  4  to  72  ounces. 
Price  varies  somewhat,  due  to  trade  conditions  in  different 
localities. 

NESTLE 's  FOOD 

Made  by  the  Nestle 's  Food  Company 
Ingredients. — The  food  is  composed  of  pure  cow's  milk, 
heated  with  cane  sugar,  condensed  at  a  low  temperature  and 
mixed  with  ground  wheaten  biscuit  in  which  most  of  the 
starch  has  previously  been  converted  "by  special  process" 
into  maltose  and  dextrin. 

How  Used. — Dissolved  in  water  without  other  diluent. 
Analysis  of  Food  as  Sold. — 

Per  cent. 

Fat 5.50 

Proteids 14.34 

Lactose  6.57 

Cane  sugar 25.00 

Dextrin  and  maltose 27.36 

Insoluble  carbohydrates 15.39 

Mineral  matter 2.03 

Moisture 3.81 

Caloric  Value. — 115.084  calories  per  ounce. 
Price  and  Size  of  Package. — 6-ounce,  25  cents;  12-ounce, 
50  cents ;  72-ounce,  $2.50. 

MELLIN'S  FOOD 
Made  by  the  Mellin's  Food  Company,  Boston,  Mass. 

Ingredients. — Maltose  and  dextrins,  with  potassium  bicar- 
bonate. Made  from  wheat  and  malted  barley,  according 
to  Liebig's  formula.  The  process  employed  converts  the 
starch  of  the  grains  into  maltose  and  dextrins. 

How  Used. — With  cow's  milk,  furnishing  carbohydrates 
(maltose  and  dextrins),  cereal  proteins  and  salts. 

24 


370  SIMPLIFIED  INFANT  FEEDING 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Fat 16 

Proteins  10.35 

Maltose 58.88 

Dextrins  .  .  20.69 


Soluble  carbohydrates 79.57 

Salts   4.30* 

Water  .  5.62 


100.00 

Analyses  of  food  mixtures  prepared  for  infants'  con- 
sumption  vary  with  formula  used. 

One  level  tablespoonful  of  Mellin's  Food  added  to  a 
16-ounce  mixture  increases  the  percentage  of  carbohydrates 
1.10-,  proteins  0.14-,  salts  0.06. 

One  level  tablespoonful  of  Mellin's  Food  added  to  a  20- 
ounce  mixture  increases  the  percentage  of  carbohydrates 
0.91-,  proteins  0.12-,  salts  0.05. 

Caloric  Value. — 

1  level  tablespoonful 25  calories 

1  ounce  avoirdupois 105  calories 

Price  and  Size  of  Package Marked  price,  10  ounces,  75 

cents ;  5  ounces,  50  cents.    Selling  price  in  East,  10  ounces, 
55  cents ;  5  ounces,  35  cents. 

BIDGE'S  FOOD 
Made  by  Kidge  's  Food  Company 

Ingredients. — "Wheat,  milk  sugar,  and  bicarbonate  of  soda. 
The  wheat  is  in  digestible  form  through  long  cooking  at 
high  temperatures. 

How  Used. — With  dilutions  of  milk  and  water  according 
to  formula. 

*  1.8  per  cent,  derived  from  cereals  and  2.5  per  cent,  potassium  bicarbonate. 


PROPRIETARY  FOODS  371 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Proteids 12.50 

Fats 26 

Carbohydrates 81.47 

Salts 61 

Water  5.16 

Analysis  of  Food  as  Prepared  for  Infants'  Consumption. — 
Variable,  but  given  with  each  formula. 

Price  and  Size  of  Package. — 8-ounce,  25  cents;  16-ounce, 
50  cents ;  2-pound,  $1 ;  3^-pound,  $1.50. 

WYETH  's  PREPARED  FOOD 
Made  by  John  Wyeth  and  Brother 

Ingredients. — Evaporated  milk,  malt,  wheat,  and  barley, 
' '  prepared  in  such  a  way  as  to  render  the  preparation  easily 
assimilable." 

How  Used. — As  a  diluent  with  milk  and  water,  warmed. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Proteid 14.25 

Fat 3.25 

Sugar  and  other  carbohydrates 72.50 

Mineral  matter 4.0 

Moisture 6.0 

Analysis  of  Food  as  Prepared  for  Infants'  Consumption. — 
Not  given,  varies  according  to  formula. 

Caloric  Value. — About  110  calories  per  ounce. 

Price  and  Size  of  Package. — 8-ounce,  35  cents;  16-ounce, 
65  cents ;  6-pound,  $2.75. 

HORLICK'S  MALTED  MILK 

Ingredients. — Full-cream  milk  combined  with  the  extracts 
of  malted  barley  and  wheat,  reduced  by  a  special  method 
and  apparatus  to  a  concentrated  powder  form  which  con- 


372  SIMPLIFIED  INFANT  FEEDING 

tains  26  per  cent,  of  milk  solids.  In  the  process  of  manu- 
facture the  starch  of  the  grains  is  converted  into  maltose 
and  dextrin,  and  the  casein  of  the  milk  is  so  modified  that 
tough,  hard  curds  cannot  be  formed  in  the  gastro-intestinal 
tract.  It  is  soluble  in  water  and  requires  no  cooking  to 
prepare  it. 

Analysis  of  Food  as  Sold. —  percent 

Fat 8.78 

Protein 16.35 

Dextrin   18.80  1    Total   soluble 

Lactose 10.65  (     carbohydrates, 

Maltose 38.50  J      67.95  per  cent. 

Inorganic  salts 3.86 

Moisture 3.06 

Analysis  of  Food  as  Prepared  for  Infants'  Consumption. — 
Not  given,  as  it  varies  according  to  the  different  formulas. 
Caloric  Value. — 121  calories  per  ounce. 
Price  and  Size  of  Package. — Small  size  (7-ounce),  50  cents ; 
large  size  (16-ounce),  $1;  family  size  (5-pound),  $3.75. 

BROOKS 's  BABY  BARLEY 
Made  by  Brooks  Barley  Company 

Ingredients. — Pure  barley  flour. 

How  Used. — With  water. 

Analysis  of  Food  as  Sold. —  Percent 

Fat 84 

Proteid  7.93 

Carbohydrates 81.41 

Mineral  matter 57 

Crude  fibre 2.56 

Moisture 6.69 

Caloric  Value. — Not  given. 

Price  and  Size  of  Package. — ^-pound,  15  cents;  1-pound, 
25  cents. 


PROPRIETARY  FOODS  373 

SWEETENED  CONDENSED  MILK 

Ingredients. — Cow's  milk  evaporated  at  a  temperature 
of  212°  F.  to  about  one-quarter  its  original  volume,  with  the 
addition  of  cane  sugar — enough  of  which  is  added  to  make 
50  per  cent,  sugar. 

How  Used.— With  the  addition  of  water. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Fats 6.94 

Proteids 8.43 

Sugar 50.69 

Salts 1.39 

Water  31.30 

Analysis  of  Food  Prepared  with  Six  Parts  of  Water. — 

Per  cent. 

Fats 99 

Proteids 1.2 

Sugar 7.23 

Salts 17 

Water 90.49 

UNSWEETENED  CONDENSED  MELK 

Ingredients. — Either  whole  or  skimmed  milk  evaporated 
to  about  one-half  or  one-third  its  original  volume,  with  the 
addition  of  cane  or  any  other  artificial  sugar. 

How  Used. — Best  used  by  adding  equal  parts  of  water, 
which  solution  is  to  be  considered  to  be  about  the  strength 
of  cow's  milk  and  may  then  be  further  modified  by  the  addi- 
tion of  gruels,  water,  and  sugar  to  suit  the  individual  infant. 

Analysis  of  Food  as  Sold. — 

Per  cent. 

Fat  8.34-10.10 

Proteids 6.     -  7.36 

Sugar 10.    -12. 


LIST  OF  CASES 

PAQB 

CASE  I. — A  case  in  which  peptonizing  the  food  did  not  overcome  the  infant's 

indigestion  or  vomiting 44 

CASE  II. — A  case  in  which  intestinal  indigestion — diarrhoea — was  overcome 

by  boiling  the  milk  46 

CASE  III. — A  case  of  intestinal  indigestion — diarrhoea — caused  by  too  much 
fat,  overcome  by  cutting  down  the  fat,  omitting  the  sugar,  and  boiling 
the  milk 48 

CASE  IV. — A  case  illustrating  the  use  of  malt  soup  extract  when  other 

kinds  of  sugar  had  caused  digestive  disturbances  51 

CASE  V. — An  unusual  case  of  sugar  idiosyncrasy  in  which  any  sugar  what- 

evef  gave  rise  to  diarrhoea 53 

CASE  VI. — A  case  in  which  the  sudden  addition  of  a  large  amount  of  sugar 
caused  intestinal  indigestion — diarrhoea — and  showing  the  importance 
of  increasing  the  sugar  gradually 55 

CASE  VII. — A  case  of  indigestion  caused  by  top  milk  and  an  excessive 
amount  of  sugar,  showing  the  necessity  of  gradually  increasing  the 
quantity  of  sugar  when  the  kind  of  sugar  is  changed 56 

CASE  VIII. — A  case  illustrating  the  method  of  feeding  an  infant,  using 

caloric  requirements  as  a  standard  64 

CASE  IX, — A  case  illustrating  the  necessity  of  an  accurate  and  routine 

method  of  mixing  and  administering  the  food 67 

CASE  X. — A  case  illustrating  feeding  a  new-born  infant  77 

CASE  XI. — A  case  illustrating  the  method  of  feeding  an  infant  three  days 

old  79 

CASE  XII. — A  case  illustrating  abrupt  weaning  of  an  infant  on  account 

of  mother's  sudden  death 81 

CASE  XIII. — A  case  illustrating  the  institution  of  fresh  cow's  milk  feed- 
ings with  a  poorly  nourished  infant  previously  fed  upon  condensed  milk  84 

CASE  XIV. — A  case  illustrating  excessive  sugar  feeding  as  well  as  over- 
feeding in  the  number  of  calories 86 

CASE  XV. — A  case  showing  an  infant  without  digestive  disturbances — 
except  for  constipation — who  had  been  fed  on  too  concentrated  a  food 
from  the  first  two  months  of  life  87 

CASE  XVI. — An  exaggerated  case  of  underfeeding  89 

CASE  XVII. — A  case  illustrating  moderate  underfeeding   90 

CASE  XVIII. — A  case  illustrating  the  use  of  the  First  Method  in  a  case 

of  simple  intestinal  indigestion  122 

CASE  XIX. — A  case  illustrating  the  use  of  the  First  Method  in  a  case 

of  underfeeding 123 

374 


LIST  OF  CASES  375 

CASE  XX. — A  case  illustrating  the  use  of  the  First  Method  in  a  case  of 

indigestion,  underfeeding  and  lowered  tolerance  124 

CASE  XXI. — Illustrating  the  use  of  the  First  Method  in  a  case  of  over- 
feeding   125 

CASE  XXII. — A  case  illustrating  the  use  of  the  First  Method  for  fermen- 
tative diarrhoea  127 

CASE  XXIII. — A  case  illustrating  the  use  of  Protein  Milk  in  severe 

intestinal  indigestion  131 

CASE  XXIV. — A  case  illustrating  the  use  of  Protein  Milk  in  diarrhoea 

which  has  been  unrelieved  by  other  methods  133 

CASE  XXV. — A  case  also  illustrating  the  use  of  Protein  Milk  where 

others  failed  134 

CASE  XXVI. — A  case  illustrating  the  use  of  the  paradoxical  weight  reaction.  137 

CASE  XXVII. — A  case  illustrating  the  use  of  the  Second  Method  for  putre- 
factive diarrhoea  142 

CASE  XXVIII. — Illustrating  the  use  of  the  Second  Method  in  overfeeding.  143 

CASE  XXIX. — A  case  illustrating  gruel  and  fat-free  diet 145 

CASE  XXX. — A  case  illustrating  the  use  of  the  Third  Method  in  a  mild 

type  of  infectious  diarrhoea  148 

CASE  XXXI. — A  case  illustrating  the  use  of  the  Third  Method  in  a  case 

of  moderately  severe  dysentery  151 

CASE  XXXII. —  A  case  illustrating  the  use  of  the  Third  Method  in  a  mild 

case  of  infectious  diarrhoea 153 

CASE  XXXIII. — A  case  illustrating  the  use  of  the  Third  Method  in 

cholera  infantum 156 

CASE  XXXIV. — A  case  illustrating  the  use  of  the  Third  Method  in  mechan- 
ical diarrhoea  159 

CASE  XXXV. — A  case  illustrating  the  use  of  whole  milk,  water  and  sugar 

to  relieve  constipation  from  excessive  fat 172 

CASE  XXXVI. — A  case  illustrating  constipation  from  too  much  sugar  ....   174 

CASE  XXXVII. — A  case  illustrating  constipation  from  too  little  sugar. . . .    176 

CASE  XXXVIII. — A  case  illustrating  constipation  from  too  weak  food. . . .   178 

CASE  XXXIX. — A  case  illustrating  constipation  from  the  excessive  use 

of  cathartics 182 

CASE  XL. — A  case  illustrating  treatment  of  acute  vomiting 188 

CASE  XLI. — A  case  illustrating  the  use  of  paregoric  for  severe  vomiting 

of  three  weeks'  duration  189 

CASE  XLII. — A  case  illustrating  habitual  vomiting  controlled  by  regu- 
lating the  amount  of  sugar  and  the  intervals  of  feeding 195 

CASE  XLIII. — A  case  illustrating  the  danger  of  omitting  the  sugar  in 

a  weak  infant  197 

CASE  XLIV.— A  case  illustrating  the  use  of  Dry  Milk  in  vomiting 200 

CASE  XLV. — A  case  illustrating  habitual  vomiting  from  overfeeding  in 

quantity,  as  well  as  from  too  strong  a  food 203 

CASE  XLVI. — A  case  illustrating  the  use  of  atropin  in  vomiting  of  the 
hypertonic  infant 


376  LIST  OF  CASES 

CASE  XLVII. — A  case  illustrating  loss  of  appetite  and  its  control  by 
reducing*  the  amount  of  milk  and  sugar  and  lengthening  thei  intervals 
between  feedings  210 

CASE  XLVIII. — A  case  illustrating  loss  of  appetite  from  overfeeding. . . .  212 

CASE  XLIX. — A  case.illustrating  a  case  in  which  loss  of  appetite  repeatedly 
recurred  whenever  the  food  was  increased  beyond  the  infant's  minimum 
caloric  requirements  213 

CASE  L. — A  case  illustrating  lack  of  appetite  and  its  treatment  in 

feeble  and  emaciated  infants 217 

CASE  LI. — A  case  illustrating  the  effect  of  mother's  overfeeding  and  its 

control  223 

CASE  LII. — A  case  illustrating  the  effect  of  mother's  underfeeding  and 

its  effect  upon  the  infant  225 

CASE  LIU. — A  case  illustrating  constipation  in  an  infant  as  a  result  of 

mother's  constipation 22!> 

CASE  LIV. — A  case  illustrating  effects  of  mother's  nervousness  upon 

her  infant 230 

CASE  LV. — A  case  illustrating  the  effect  of  regularity  of  feeding  in  improv- 
ing an  infant's  digestive  disturbances  233 

CASE  LVI. — A  case  illustrating  the  benefit  of  adjusting  feeding  details  to 

suit  the  infant  , 234 

CASE  LVII. — A  case  illustrating  the  effect  of  using  a  nipple  shield  ....  235 

CASE  LVIII. — A  case  illustrating  the  relief  from  colic  obtained  by  shorten- 
ing the  feedings  243 

CASE  LIX. — A  case  illustrating  the  immediate  necessity  of  complemental 

feedings  for  emaciation  345 

CASE  LX. — A  case  illustrating  complemental  feedings  for  underfeeding  . .   247 

CASE  LXI. — A  case  illustrating  severe  vomiting  caused  by  breast  milk, 

and  eventually  remedied  by  stopping  the  breast  feedings  251 

CASE  LXII. — A  case  illustrating  temporary  discontinuations  of  the  breast 

milk  on  account  of  operation  upon  mother  256 

CASE  LXIII. — A  case  showing  an  infant  of  fifteen  months  who  refused 
solid  food  because  it  was  weaned  from  the  breast  to  the  bottle  at  ten 
months  of  age 259 

CASE  LXIV. — A  case  illustrating  the  correct  method  of  weaning  an  infant 

of  eight  months  of  age  or  older  261 

CASE  LXV. — A  case  illustrating  persistent  diarrhoea  in  an  infant  progress- 
ing normally  otherwise  265 

CASE  LXVT. — A  case  illustrating  acute  diarrhoea  in  the  breast-fed  infant 

and  its  treatment  267 

CASE  LXVII. — A  ease  illustrating  diarrhoea  in  breast-fed  infant  from 

irrational  food  268 

CASE  LXVIII. — A  case  illustrating  constipation  from  too  frequent  and 

irregular  feedings  271 

CASE  LXIX. — A  case  illustrating  the  control  of  constipation  in  a  breast- 
fed infant  by  treating  the  constipation  of  the  mother  272 


LIST  OF  CASES  377 

CASE  LXX. — A  case  illustrating  constipation  due  to  insufficient  breast 

milk  and  underfeeding  of  infant  273 

CASE  LXXI. — A  case  illustrating  the  manner  in  which,  curds  repeatedly 

occur  in  the  stools  when  raw  milk  is  substituted  for  boiled  milk. .  . .  281 

CASE  LXXII. — A  case  in  which  boiled  milk  feedings  had  to  be  used  through- 
out the  bottle  period  because  raw  milk  caused  severe  intestinal 
indigestion  282 

CASE  LXXIII. — A  case  in  which  the  stools  were  made  normal  by  boiling 

the  milk  without  changing  the  milk  in  any  other  way 286 

CASE  LXXIV. — A  case  illustrating  intestinal  indigestion  in  which  the 
diarrhoea  persisted  with  raw  milk  mixtures,  but  was  promptly  relieved 
upon  boiling  the  same  mixture  287 

CASE  LXXV. — A  case  illustrating  the  use  of  Dry  Milk  when  the  usual 

milk  mixtures  disagreed  294 

CASE  LXXVI. — A  case  illustrating'  rapid  increase  in  tolerance  when  using 

Dry  Milk  296 

CASE  LXXVI  I. — A  case  illustrating  the  use  of  Dry  Milk  in  the  worst 

feeding  case  imaginable 298 

CASK  LXXVIII. — A  case  illustrating  the  use  of  malt  soup  feedings....   304 

CASE  LXXIX. — A  case  illustrating  the  use  of  malt  soup  mixtures 306 

CASE  LXXX. — A  case  illustrating  the  weaning  of  a  bottle-fed  infant  of 

eight  months  of  age 319 


LIST  OF  TABLES 

PAGE 

Average  Height  of  Normal   Infants    345 

Average  Weight  of  Normal  Infants 345 

Caloric  Requirements  of  Bottle-fed  Infants 58 

Caloric  Value  of  Milk  with  Different  Percentages  of  Fat  379 

Caloric  Value  of  Infants'  Food 58 

Causes  of  Constipation  in  Bottle-fed  Infants 171 

Causes  of  Constipation  in  Breast-fed  Infants   270 

Causes  of  Habitual  Vomiting  in  Breast-fed  Infants  269 

Classification  of  Diarrhoeas  in  Bottle-fed  Infants   100 

Classification  of  Vomiting  in  Bottle-fed  Infants    184 

Conditions  under  Which  Breast  Feeding  Should  be  Continued  Exclusively.  221 
Conditions  under  Which,  Breast  Feeding  Should  be  Temporarily  Discon- 
tinued      255 

Contra-indications  for  Breast  Feeding  250 

Diarrhoea  in   Breast-fed  Infants    264 

Differential  Diagnosis  of  Diarrhoea 113 

Errors  in  Administering  Bottle  Feedings  192 

Facts  to  be  Ascertained  in  Every  Case  of  Diarrhoea 93 

Kinds  of  Adulteration  of  Milk  Forbidden  in  New  York  City 355 

Regulations  Governing  Grades  and  Designation  of  Milk  and  Cream  which 

may  be  Sold  in  the  City  of  New  York 356-357 

Rules  and  Regulations  for  the  Sale  of  Dipped  Milk  and  Cream  in  Stores  in 

the  City  of  New  York 359 

Symptoms  Indicative  of  Sviccessful  Breast  Feeding 220 

Symptoms.  Indicative  of  Unsuccessful  Breast  Feeding 221 

Treatment  of  Acute  Vomiting 185 


378 


CALORIC  VALUE  OF  MILK 


379 


CALORIC  VALUE  OF  MILK  WITH  DIFFERENT  PAT  PERCENTAGES 


One  ounce  of  milk 

Coloric 

How  obtained  from  1  quart  o: 

milk  set  until  cream  all  rises 

containing  fat 

value 

Average  milk,  4  per  cent. 

Rich  milk,  5  per  cent. 

Per  cent. 
12 

40 

Top    8  ounces  

Top  11  ounces 

11 

37.5 

Top  10  ounces  

Top  12  ounces. 

10 

35 

Top  11  ounces  

Top  13  ounces. 

9 

32.5 

Top  13  ounces  

Top  14  ounces. 

8 

30 

Top  14  ounces  

Top  16  ounces. 

7 

27.5 

Top  16  ounces  

Top  20  ounces. 

6 

25 

Top  20  ounces  

Top  24  ounces. 

5 

22.5 

Top  24  ounces  

All. 

4 

20 

All  

Remainder   after   skim- 

3 
2 

1 

Fat-free  milk  
Whey  

17.5 
15 
12.5 

10 
10 

Remainder   after   skim- 
ming off  2  ounces 
Remainder   after   skim- 
ming off  4  ounces 
Remainder   after   skim- 
ming off  8  ounces 
Centrif  ugalized  . 

ming  off  2  ounces. 
Remainder    after    skim- 
ming off  3  ounces. 
Remainder    after    skim- 
ming off  5  ounces. 
Remainder    after    skim- 
ming off  8  ounces. 

Condensed  milk.  . 

132 

INDEX 


Abdomen,  examination  of,  30 
Acetone  in  acidosis,  161 
Aeidosis,   160 

treatment  of,  165 
Acute  vomiting,  184 

in  the  breast-fed,  269 
Albumin  milk,  128 
Alkali  treatment  in  acidosis,  165 
Alkalies  in  the  food,  42 
Allenbury's  Food,  361 
Appetite,  in  constipation,  180 

loss  of,  in  the  bottle-fed,  209 

of  nursing  mother,  227 

taking  history  of,  25 
Atropin  in  vomiting,  205 

Babies'  Food,  364 
Bacteria  in  milk.  351 
Barley  gruel,  330 

in  diarrhoea,  139 

Belly-bands,  cause  of  vomiting,  194 
Benger's  Food,  364 
Blood  in  stools,  98 
Bloody  diarrhoea,  treatment  of,  149 
Boiled  milk  in  diarrhoea,  120 

in  infant  feeding,  275 
Boiling  milk,  method  of,  120 
Bony  development,  31 
Bottle  weaning,  315 
Bottles,  description  of,  34 

care  of,  34 
Bowel  irrigation,  341 
Bowels  of  nursing  mothe.,  227 

taking  history  of,  24 
Breads,  325 
Bread-pap,    141 
Breast  and  bottle  feedings  combined, 

244 

Breast-fed  infant,  constipation  in,  270 
diarrhoea,  264 
vomiting,  269 


Breast-feeding,  220 

common  errors  in,  233 
centra-indications  for,  250 
indications   of   success,   220 
mother's  diet  in,  222 
of  new-born  infants,  239 
temporary  discontinuation  of,  255 

Breast  milk,  examination  of,  237 
percentages  in,  37 

Breast  pump,  235 

Breast  weaning,  81,  258 

Breasts,  treatment  of,  during  wean- 
ing, 263 

Broths,  330 

Calomel,  abuse  of,  121 

cause  of  vomiting,  186 
Caloric  requirements,  conditions  under 
which  they  should  not  be  ful- 
filled, 74 

of  bottle-fed  infants,  58 
value  of  Dry  Milk,  295,  300 
values  of  infant  foods,  58 
Calories,  definition  and  description  of, 

57 

rough  rule  for  reckoning,  72 
Carbohydrate  diet  in  diarrhoea,  139 
Cane  sugar,  49 
Casein  in  milk,  42 
Cathartics,  98 

in  constipation,  181 
in  diarrhoea,  121 
in  vomiting,  185 
Cereals,  325 
Cereo,  330 
Certified  milk,  349 
Cholera  infantum,  diagnosis  of,  111 

treatment  of,  154 
Chronic  diarrhoea,  145 
Colic  in  the  breast-fed,  250 
in  nursing  infants,  241 

381 


382 


INDEX 


Coma  in  acidosis,  161 

Combined  breast  and  bottle  feedings, 

244 

Complemental  feedings,  246 
Constipation  due  to  boiled  milk,  289 

in  bottle-fed  infants,  170 

in  the  breast-fed,  270 

treatment  of,  170 
Contra-indications  for  breast-feeding, 

250 

Cow's  milk,  347 
Curds  in  stools,  96 

of  milk,  38 

Decomposition,  112 
Desserts,  328 
Development,  28 
Dextri -maltose,  50 

in  constipation,  174 
Dextrinized  gruels,  330 
Diarrhoea,  93 

boiled  milk  in,  285 

carbohydrate  diet  for,  139 

chronic,  145 

classification  of,  100 

differential  diagnosis  of,   113 

due  to  overfeeding,  104 

due  to  underfeeding,  103 

fermentative,  106 

first  method  of  treating,  118 

from  sugar,  53 

infectious,  110 
treatment  of,  147 

in  the  breast-fed,  250,  264 

mechanical,  112 
treatment  of,  159 

protein  diet  in,  118 

protein  milk  in,  128 

putrefactive,  107 
treatment  of,  139 

second  method  of  treating,  139 

sugar  in,    118 

third  method  of  treating,  147 

treatment  of,  115 
Diet,  12  to  14  months,  321 

14  to  15  months,  332 


Diet,  at  2  years,  323 

at  2%  years,  324 

during  weaning,  319 

of  mother  in  breast-feeding,  222 

of  nursing  mother,  222 

in  weaning,  260 
Digestibility  of  food,  42 
Directions  for  making  foods,  general, 

31 

Dryco  Brand  Dry  Milk,  300 
Dry  Milk,  291 

for  premature  infants,  336 
in  travelling,  337 
in  vomiting,  200 
Dysentery,  110 

treatment  of,  149 

Eclamptic  mothers,  253 
Eggs,  327 
Eiweiss  Milch,  128 
Elements  in  the  food,  proper,  37 
Emaciated    infants,    caloric    require- 
ments of,  58 
Eskay's  Food,  367 
Examination,  physical,  27 

Facial  expression,  30 
Fat,  cause  of  vomiting,  194 
of  constipation,  171 

diarrhoea  due  to,  102 

indigestion,  46,  121 

in  Dry  Milk,  300 

digestibility  of,  47 
Fats,  percentage  of,  39 
Feeding  blank  for  mother,  32 
Feeding,  intervals,  63 

normal  infant  from  birth,  68 

new-born  infants,  75 

quantity  given  in  a  single,  62 

times  and  intervals  of  the  breast- 
fed, 232 

Fermentative  diarrhoea,  106 
Flour,  caloric  value  of,  58 
Fontanel,  346 
Food  for  travelling,  337 
Fruits,  329 


INDEX 


383 


Gavage,  341 

for  loss  of  appetite,  216 
Gruels,  330 

in  diarrhoea,   139 

use  of,  in  infant  feeding,  43 
Gas  in  the  stomach,  193 

Habit  as  a  cause  of  constipation,  182 
Habitual  vomiting,  191 

in  the  breast-fed,  269 
Height  of  normal  infant,  345 
History  taking,  22 
Hypertonic  infant,  204 
Hypodermoclyeis,   166 

Imperial  Granuni,  368 

Ileocolitis,  110 

Incubator,  333 

Indigestion,  caused  by  fats,  47 

by  sugar,  49 
in  nursing  infants,   241 
intestinal,   100 
Infectious  diarrhoea.  100,  110 

treatment  of,  147 
Intervals  of  feeding,  63 
Intervals    and   feeding   times   of   the 

breast-fed,  232 
Intestinal  indigestion,  100 
diagnosis  of,  105 
boiled  milk  in,  285 
Intestinal    intoxication,    acidosis    ac- 
companying, 160 

Intoxication,    intestinal,   acidosis   ac- 
companying,   160 
sugar,  107,  112,  158 
Intraperitoneal  injection  of  salt  solu- 
tion, 166 

Jaundice  in  nursing  infants,  241 
Junket,  331 

Keller's  Malt  Soup,  51,  302 

Lactose,  50 
Lavage,  339 

in  vomiting,  186,  187 


Laxative  action  of  sugar,  50 
Lime  water,  42 
Loss  of  appetite,  209 

Malt  soup,  51 

caloric  value  of,  58 
in  constipation,  174 
mixtures,  302 
Malt  sugar,  49 
Marasmus,  112 

protein  milk  in,  135 
Meat,  327 
Mechanical  diarrhoea,  112 

treatment  of,  159 
Mellin's  Food,  369 

Menstruation  of  nursing  mother,  257 
Milk,  adulteration  of,  355 

as  a  cause  of  contagion,  351 

bacteria   in,   351 

caloric  value  of,  58 

chemical   composition  of,  347 

grades  of,  358 

pasteurization  of,  354 

production  of,  347 

sterilization  of,  354 
Milk  sugar,  50 

Milk  of  magnesia  in  constipation,  183 
Mineral  salts  in  milk,  309 
Mixing  the  food,  35 
Morphine  in  diarrhoea,  155 
Mouth,  condition  of,  29 
Mucus  in  stools,  97 

Nestle's  Food,  369 

New-born  infants,  breast-feedings  of, 

239 
feeding    of,    who    refuse    the 

breast,  239 
Nipples,  35 
Nipple  shield.  235 
Normal  infants,  feeding,  68 
Normal  saline,  use  of,  166 
Nutritional  condition,  28 

Odor  of  stools,  96 

Older  children,  diet  of,  315 


384 


Orange  juice,  72 
Overfed  infants,  85 
Overfeeding,  diarrhoea  in,  104 

in  the   breast-fed,   264 

treatment  of,  125 

Paregoric  in  vomiting,  187 
Pasteurization  of  milk,  354 
Percentage  in  breast  milk,  37 

of  cow's  milk,  347 

of  Dry  Milk,  300 
Peptonizing  the  food,  42 
Physical  examination,  27 
Pregnancy  of  nursing  mother,  254 
Premature  infant,  332 
Proprietary  foods,  361 
Proteid  indigestion,  121 
Proteids,  digestibility  of,  42 

in  Dry  Milk,  299 

percentage  of,  38 
Protein  diet  in  diarrhoea,  118 

indigestion,  46 

milk,    128 
Putrefactive  diarrhoea,  107 

treatment  of,  139 
Pyloric  stenosis,  208 
Pyloro-spasm,  208 

Quantity  given  in  a  single  feeding,  62 
Quantity  of  food  in  vomiting,  201 
to  supply  the  caloric  needs,  57 
of  sugar,  54 

Reaction  of  the  stools,  96 
Rickets  caused  by  dry  milk,  297 

evidences  of,  31 

from  boiled  milk,  277 

Saline  solution,  use  of,  166 
Salts  of  milk,  41,  309 
Salt  solution,  use  of,  166 
Scales,  26 
Scurvy,  277 

Dry  Milk  in,  207 


Sedatives  in  vomiting,  187 

Shiga  bacillus,   111 

Sodium  bicarbonate  and  citrate,  use 

of  in  infant  feeding,  43 
in  acidosis,  161 
in  vomiting,   185 
Soups,  328,  330 
Starch,  cause  of  vomiting,  194 
Stomach,  capacity  of,  62 

motility,  202 
Stools,  93 

blood  in,  98 

curds  in,  96 

mucus  in,  97 

odor  of,    110 

reaction  of,  110 

taking  history  of,  24 
Strychnia,  for  loss  of  appetite,  213 
Sugar,  caloric  value  of,  58 

cause  of  vomiting,  194 

diarrhoea,  53,  103 

digestibility  of,  49 

dyspepsia,  50 

in  constipation,  173 

in  diarrhoea,  118 

indigestion,  46,  121 

intoxication,  107,   112,   158 

kind  of,  49 

milk,   malt   or   cane,   49 

of  milk,  50 

percentage  of,  40 

quantity  of,  54 

rules  for  using,  54 
Supplemental  feedings,  246 
Synopsis  of  text,  1 
Syphilis  of  breast-fed  infants,  254 

Teeth,   346 

Teething,  29 

Three     essential     requirements      for 

infants'  foods,  37 
Tolerance  for  food,  105 
Travelling,  food  for,  337 
Tuberculosis  due  to  milk,  351 

of  nursing  mother,  254 


INDEX 


385 


Underfed  infants,  89 
Underfeeding,  diarrhoea,  103 

treatment  of,  123 
Use  of  boiled  milk  in  infant  feeding, 

275 
Utensils  for  bottle-feeding,  34 

Vegetables,  326 

Vomiting,  as  cause  of  constipation,  180 

cause  of,  184-191 

Dry  Milk  in,  293 

habitual,  191 

in  bottle-fed  infants,  184 

in  breast-fed  infants,  269 

of  hypertonic  infant,  204 


Vomiting,   organic   causes   of,   208 
taking  history  of,  25 
treatment   of,    184 

Water,  338 

for  new-born  infants,  239 

in  the  food,  61 

in  vomiting,  185 
Weaning  from  the  bottle,  315 

from  the  breast,  81,  258 

treatment  of  the  breasts  in,  263 
Weight,  26 

determining  factor  of  caloric  needs, 
58 

of  normal  infant,  345 
Whey,  42 


Date  Due 


PRINTED    IN    U.S.*.  CAT.      NO.      24       161 


IHIIIMIII  Ml"  ••'""•' 

A    000417011     4 


WS120 
D399s 
1920 
Dennett,  Roger  H 

Simplified  infant  feeding. 


WS120 
D399s 
1920 
Dennett,  Roger  H 

Simplified  infant,  feeding 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


